Provider Demographics
NPI:1407528771
Name:REIVITIS, ALEXANDRA NICOLE
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:REIVITIS
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 1:2827 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-3821
Mailing Address - Country:US
Mailing Address - Phone:310-428-1267
Mailing Address - Fax:
Practice Address - Street 1:360 HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5000
Practice Address - Country:US
Practice Address - Phone:617-373-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA61956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program