Provider Demographics
NPI:1912441270
Name:BRAVO, KAYLA MARIE (DC)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:MARIE
Last Name:BRAVO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:MARIE
Other - Last Name:GOULART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1768 PARKDALE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-4640
Mailing Address - Country:US
Mailing Address - Phone:408-903-6008
Mailing Address - Fax:
Practice Address - Street 1:100 OCONNOR DR STE 25
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1638
Practice Address - Country:US
Practice Address - Phone:408-271-2800
Practice Address - Fax:408-263-0331
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC34252111N00000X
AZ8596111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty