Provider Demographics
NPI:1396855813
Name:BRACY, JUANITA DENAE (PA-C, MPA, ATC, MED)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:DENAE
Last Name:BRACY
Suffix:
Gender:F
Credentials:PA-C, MPA, ATC, MED
Other - Prefix:MS
Other - First Name:JUANITA
Other - Middle Name:DENAE
Other - Last Name:HOLLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:700 N PEARL ST STE N208
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-7430
Mailing Address - Country:US
Mailing Address - Phone:214-999-9355
Mailing Address - Fax:
Practice Address - Street 1:700 N PEARL ST STE N510
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-2863
Practice Address - Country:US
Practice Address - Phone:214-580-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0120008642255A2300X
CA2255A2300X
NC306479363AM0700X
CAPA60497363AM0700X
363AM0700X
TXPA15256363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0126000864OtherATC VIRGINIA LICENSE
TXPA15256Medicaid
CA0070402592OtherNATA BOC