Provider Demographics
NPI:1619278819
Name:KELLOGG, ALEXANDRA (DC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 W MAIN ST
Mailing Address - Street 2:PO BOX 365
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986
Mailing Address - Country:US
Mailing Address - Phone:920-706-0178
Mailing Address - Fax:920-703-0179
Practice Address - Street 1:238 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNECONNE
Practice Address - State:WI
Practice Address - Zip Code:54986
Practice Address - Country:US
Practice Address - Phone:920-706-0178
Practice Address - Fax:920-703-0179
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4667-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4667-012OtherSTATE OF WISCONSIN