Basic Information
| Provider Information | |||||||||
| NPI: | 1801068333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHARNETZKY | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | MICHELE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20617 EASTGOLDEN ELM DR | ||||||||
| Address2: | |||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339283471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473074 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9911 CORKSCREW RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339283323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397682111 | ||||||||
| FaxNumber: | 2394824404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2008 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 258683 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | OS13547 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 015615700 | 05 | FL | MEDICAID |