Provider Demographics
NPI:1568801207
Name:ALEJANDREZ, MICHELLE CAROL
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CAROL
Last Name:ALEJANDREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:CAROL
Other - Last Name:ASENCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:142 W 5TH ST APT 7
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2155
Mailing Address - Country:US
Mailing Address - Phone:626-696-0028
Mailing Address - Fax:
Practice Address - Street 1:142 W 5TH ST APT 7
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2155
Practice Address - Country:US
Practice Address - Phone:626-696-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-16
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36797167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician