Basic Information
| Provider Information | |||||||||
| NPI: | 1689881310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAVO | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | VICUNA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603397254 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1415 ROSS AVE | ||||||||
| Address2: | CALEXICO OUTPATIENT CENTER | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603570508 | ||||||||
| FaxNumber: | 7603570817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP16654 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LF0000X | 16654 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN430309 | 05 | CA | MEDICAID | 16654 | 01 | CA | FNP PROVIDER | OTHER | 1689881310 | 05 | CA | MEDICAID |