Provider Demographics
NPI:1033739040
Name:GIEDD, ALEXANDRA JILLAYNE
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JILLAYNE
Last Name:GIEDD
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 1:2641 SHENANDOAH AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6122
Mailing Address - Country:US
Mailing Address - Phone:240-418-8382
Mailing Address - Fax:
Practice Address - Street 1:2630 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4318
Practice Address - Country:US
Practice Address - Phone:704-355-9584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125077001207Q00000X
390200000X
NC2023-01867207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program