Provider Demographics
NPI:1225486160
Name:THEISEN, ALEXANDRA NICOLE (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:THEISEN
Suffix:
Gender:F
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-633-7365
Mailing Address - Fax:314-977-8818
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-633-7365
Practice Address - Fax:314-977-8818
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022019876208000000X, 2080P0216X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program