Provider Demographics
NPI:1073115242
Name:TRINE, ALEXA
Entity Type:Individual
Prefix:MS
First Name:ALEXA
Middle Name:
Last Name:TRINE
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 1:1047 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2805
Mailing Address - Country:US
Mailing Address - Phone:419-439-5394
Mailing Address - Fax:
Practice Address - Street 1:1047 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2805
Practice Address - Country:US
Practice Address - Phone:419-439-5394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0192231Medicaid