Provider Demographics
NPI:1518412345
Name:WILMARTH, ALEXA DIAMOND (NP)
Entity Type:Individual
Prefix:MRS
First Name:ALEXA
Middle Name:DIAMOND
Last Name:WILMARTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:ALEXA
Other - Middle Name:DIAMOND
Other - Last Name:BOUBALOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:650 CLARK WAY
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-2300
Mailing Address - Country:US
Mailing Address - Phone:650-218-6665
Mailing Address - Fax:
Practice Address - Street 1:650 CLARK WAY
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304
Practice Address - Country:US
Practice Address - Phone:650-326-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009707363LP0808X
CA95104937163WP0807X, 163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health