Healthcare Provider Details

I. General information

NPI: 1053196287
Provider Name (Legal Business Name): MAYERLY ALEXANDRA BRAVO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11855 SUNLIND DR
SAINT LOUIS MO
63127-1657
US

IV. Provider business mailing address

11855 SUNLIND DR
SAINT LOUIS MO
63127-1657
US

V. Phone/Fax

Practice location:
  • Phone: 916-753-0128
  • Fax:
Mailing address:
  • Phone: 916-753-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberNA
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberNA
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: