Provider Demographics
NPI:1386828978
Name:BACK, ALEXANDRA D (NP)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:D
Last Name:BACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:179 N 6TH ST
Mailing Address - Street 2:3RD FLOOR, STREET TO HOME
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-3207
Mailing Address - Country:US
Mailing Address - Phone:718-360-8034
Mailing Address - Fax:718-360-8005
Practice Address - Street 1:179 N 6TH ST
Practice Address - Street 2:3RD FLOOR, STREET TO HOME
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-3207
Practice Address - Country:US
Practice Address - Phone:718-360-8034
Practice Address - Fax:718-360-8005
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401098363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health