Provider Demographics
NPI:1518625987
Name:KULICK, ALEXA RAE
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:RAE
Last Name:KULICK
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 1:3903 FAIR RIDGE DR STE 218
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2945
Mailing Address - Country:US
Mailing Address - Phone:703-870-3750
Mailing Address - Fax:
Practice Address - Street 1:3903 FAIR RIDGE DR STE 218
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2945
Practice Address - Country:US
Practice Address - Phone:703-405-7292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008424363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant