Provider Demographics
NPI:1942959051
Name:BRACEWELL, SUSANA LEA
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:LEA
Last Name:BRACEWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 ASHCRAFT LN APT K
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2466
Mailing Address - Country:US
Mailing Address - Phone:980-297-8444
Mailing Address - Fax:
Practice Address - Street 1:1350 S KINGS DR FL 3
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1242
Practice Address - Fax:704-446-1241
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program