Provider Demographics
NPI:1083120497
Name:STORTZ, ALEXA RAE (NP)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:RAE
Last Name:STORTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALEXA
Other - Middle Name:RAE
Other - Last Name:ESTERLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:29992 NORTHWESTERN HWY STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3292
Mailing Address - Country:US
Mailing Address - Phone:248-851-1430
Mailing Address - Fax:248-851-5182
Practice Address - Street 1:33259 DEQUINDRE RD STE C
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4628
Practice Address - Country:US
Practice Address - Phone:248-588-1885
Practice Address - Fax:248-928-0617
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704288159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083120497Medicaid
MIMI4989635OtherMEDICARE PTAN