Provider Demographics
NPI:1902995301
Name:BRAVO, MICHELLE (RD, LD,CDE)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:RD, LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 POMPANO DRIVE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110
Mailing Address - Country:US
Mailing Address - Phone:239-287-9498
Mailing Address - Fax:
Practice Address - Street 1:657 POMPANO DRIVE
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110
Practice Address - Country:US
Practice Address - Phone:239-287-9498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2459133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKR670761Medicare PIN