Provider Demographics
NPI:1346898731
Name:ALEXIS, KETSIA
Entity Type:Individual
Prefix:
First Name:KETSIA
Middle Name:
Last Name:ALEXIS
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 1:1324 ROCKAWAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-2339
Mailing Address - Country:US
Mailing Address - Phone:347-641-7372
Mailing Address - Fax:
Practice Address - Street 1:1324 ROCKAWAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-2339
Practice Address - Country:US
Practice Address - Phone:347-641-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07834000164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse