Provider Demographics
NPI:1558109108
Name:BRAVO, ALEXANDRA ELIZABETH (IBCLC)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:ELIZABETH
Last Name:BRAVO
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 W GAMBRELL ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-2206
Mailing Address - Country:US
Mailing Address - Phone:682-802-9764
Mailing Address - Fax:
Practice Address - Street 1:1509 W GAMBRELL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-2206
Practice Address - Country:US
Practice Address - Phone:682-802-9764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-315102174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN