Provider Demographics
NPI:1417524745
Name:GRANDE, ALEXA TOMISSA (PA)
Entity Type:Individual
Prefix:MS
First Name:ALEXA
Middle Name:TOMISSA
Last Name:GRANDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MANCHESTER FARM RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-3340
Mailing Address - Country:US
Mailing Address - Phone:401-533-3231
Mailing Address - Fax:
Practice Address - Street 1:115 MANCHESTER FARM RD
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-3340
Practice Address - Country:US
Practice Address - Phone:401-533-3231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
RIPA01318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant