MEDICARE: ALEXANDRA ELIZABETH BRAVO IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)	L-315102	TX

General Provider Information

NPI Number	:	1558109108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA ELIZABETH BRAVO IBCLC

Provider Business Mailing Address
First Line	:	1509 W GAMBRELL ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-2206
Country	:	US
Telephone Number	:	682-802-9764
Fax Number	:

Provider Business Practice Location Address
First Line	:	1509 W GAMBRELL ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-2206
Country	:	US
Telephone Number	:	682-802-9764
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2024
Last Update Date	:	07/17/2024

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