Provider Demographics
NPI:1467901785
Name:LEE, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:LEE
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 1:2801 W HEARTWOOD CT APT H
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5259
Mailing Address - Country:US
Mailing Address - Phone:317-514-0240
Mailing Address - Fax:
Practice Address - Street 1:107 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7000
Practice Address - Country:US
Practice Address - Phone:812-855-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0279-6889OtherEMT