MEDICARE: STEPHANIE BRAGG SLACK NP

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	363LF0000X	Family Nurse Practitioner	803296	TX

General Provider Information

NPI Number	:	1619417268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE BRAGG SLACK NP

Provider Business Mailing Address
First Line	:	6242 PALO PINTO AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3616
Country	:	US
Telephone Number	:	214-707-6428
Fax Number	:

Provider Business Practice Location Address
First Line	:	6242 PALO PINTO AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3616
Country	:	US
Telephone Number	:	214-707-6428
Fax Number	:

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

Provider Enumeration Date	:	03/01/2017
Last Update Date	:	04/11/2022

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