1801068333 NPI number — MRS. NICOLE MICHELE BRUNO DO

Table of content: MRS. NICOLE MICHELE BRUNO DO (NPI 1801068333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801068333 NPI number — MRS. NICOLE MICHELE BRUNO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNO
Provider First Name:
NICOLE
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHARNETZKY
Provider Other First Name:
NICOLE
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801068333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20617 EASTGOLDEN ELM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESTERO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33928-3471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-547-3074
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9911 CORKSCREW RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ESTERO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33928-3323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-768-2111
Provider Business Practice Location Address Fax Number:
239-482-4404
Provider Enumeration Date:
03/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  258683 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: OS13547 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 015615700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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