Provider Demographics
NPI:1356083968
Name:GROSS, ALEXANDRA SHADE (CRNP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:SHADE
Last Name:GROSS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-567-4311
Mailing Address - Fax:334-514-3686
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1625
Practice Address - Country:US
Practice Address - Phone:334-567-4311
Practice Address - Fax:334-514-3686
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-152055363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL285542Medicaid
AL04220120OtherAANP
AL1-152055OtherABN MEDICAL LICENSE