Healthcare Provider Details

I. General information

NPI: 1740169804
Provider Name (Legal Business Name): LASHUNDA BRACEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4364 WESTERN CENTER BLVD UNIT 5128
FORT WORTH TX
76137-2043
US

IV. Provider business mailing address

4364 WESTERN CENTER BLVD UNIT 5128
FORT WORTH TX
76137-2043
US

V. Phone/Fax

Practice location:
  • Phone: 346-327-6137
  • Fax:
Mailing address:
  • Phone: 346-327-6137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number68248
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: