Provider Demographics
NPI:1477187169
Name:PHELPS, ALEXANDRA RAE (APRN)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:RAE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9960
Mailing Address - Fax:239-343-9977
Practice Address - Street 1:8380 RIVERWALK PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8758
Practice Address - Country:US
Practice Address - Phone:239-343-9960
Practice Address - Fax:239-343-9977
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006293364SM0705X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105748600Medicaid