Provider Demographics
NPI:1073053310
Name:SOUTHWELL, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:SOUTHWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SOUTHWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3191B MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-3395
Mailing Address - Country:US
Mailing Address - Phone:607-895-7983
Mailing Address - Fax:
Practice Address - Street 1:3191B MAIN ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3395
Practice Address - Country:US
Practice Address - Phone:607-895-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325795164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse