Provider Demographics
NPI:1033888292
Name:STAMBACH, ALEXIS JANE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:JANE
Last Name:STAMBACH
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 1:5359 30TH AVE S # 1-101
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8977
Mailing Address - Country:US
Mailing Address - Phone:218-850-1303
Mailing Address - Fax:
Practice Address - Street 1:1530 1ST AVE N STE 150
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2278
Practice Address - Country:US
Practice Address - Phone:218-307-7172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other