Healthcare Provider Details

I. General information

NPI: 1164565180
Provider Name (Legal Business Name): LETICIA BRAVO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N RACE ST
GLASGOW KY
42141-3474
US

IV. Provider business mailing address

1411 N RACE ST
GLASGOW KY
42141-3474
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-9755
  • Fax: 270-651-7562
Mailing address:
  • Phone: 270-651-9755
  • Fax: 270-651-7562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number171002
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: