Provider Demographics
NPI:1801068333
Name:BRUNO, NICOLE MICHELE (DO)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MICHELE
Last Name:BRUNO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MICHELE
Other - Last Name:CHARNETZKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20617 EASTGOLDEN ELM DR
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-3471
Mailing Address - Country:US
Mailing Address - Phone:607-547-3074
Mailing Address - Fax:
Practice Address - Street 1:9911 CORKSCREW RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-3323
Practice Address - Country:US
Practice Address - Phone:239-768-2111
Practice Address - Fax:239-482-4404
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258683208000000X
FLOS13547208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015615700Medicaid