1396855813 NPI number — MRS. JUANITA DENAE BRACY PA-C, MPA, ATC, MED.

Table of content: MRS. JUANITA DENAE BRACY PA-C, MPA, ATC, MED. (NPI 1396855813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396855813 NPI number — MRS. JUANITA DENAE BRACY PA-C, MPA, ATC, MED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRACY
Provider First Name:
JUANITA
Provider Middle Name:
DENAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C, MPA, ATC, MED.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLLEY
Provider Other First Name:
JUANITA
Provider Other Middle Name:
DENAE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396855813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 N PEARL ST STE N208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75201-7430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-999-9355
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 N PEARL ST STE N510
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75201-2863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-580-7277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  012000864 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2255A2300X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 306479 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA60497 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA15256 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0126000864 . This is a "ATC VIRGINIA LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PA15256 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0070402592 . This is a "NATA BOC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".