Provider Demographics
NPI:1437884491
Name:POMERVILLE, ALEXIS (PTA)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:POMERVILLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 KING ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1142
Mailing Address - Country:US
Mailing Address - Phone:315-713-5660
Mailing Address - Fax:315-393-0055
Practice Address - Street 1:214 KING ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1142
Practice Address - Country:US
Practice Address - Phone:315-713-5660
Practice Address - Fax:315-393-0055
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
NY013393225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant