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General NPI Number Information
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NPI Number | 1922545227
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Entity Type | Individual
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Provider Name | LACEY DENNIS BRACKEN MS,LAT,ATC
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Gender | Female
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Dates
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Enumeration Date | 01/24/2017
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Last Update Date | 04/17/2020
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Provider Practice Location Address
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Address Line | 1149 W 13TH ST
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City | JACKSONVILLE
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State | FL
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Zip | 32209-5610
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Country | US
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Telephone | 770-778-1938
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Fax |
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Provider Business Mailing Address
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Address Line | 7491 MISHKIE DR
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City | JACKSONVILLE
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State | FL
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Zip | 32244-8157
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Country | US
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Telephone | 770-778-1938
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL4863
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License Number State | FL
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