Healthcare Provider Details

I. General information

NPI: 1801068333
Provider Name (Legal Business Name): NICOLE MICHELE BRUNO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MICHELE CHARNETZKY

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9911 CORKSCREW RD SUITE 101
ESTERO FL
33928-3323
US

IV. Provider business mailing address

20617 EASTGOLDEN ELM DR
ESTERO FL
33928-3471
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-2111
  • Fax: 239-482-4404
Mailing address:
  • Phone: 607-547-3074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number258683
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS13547
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: