Provider Demographics
NPI:1326690587
Name:CLARK, ALEXANDRA GRACE (HID)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:GRACE
Last Name:CLARK
Suffix:
Gender:F
Credentials:HID
Other - Prefix:MS
Other - First Name:LEXI
Other - Middle Name:GRACE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HID
Mailing Address - Street 1:393 DUNLAP ST N STE 115
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4203
Mailing Address - Country:US
Mailing Address - Phone:651-646-2427
Mailing Address - Fax:651-649-3018
Practice Address - Street 1:393 DUNLAP ST N STE 115
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4203
Practice Address - Country:US
Practice Address - Phone:651-646-2427
Practice Address - Fax:651-649-3018
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2861237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist