Provider Demographics
NPI:1649575762
Name:STOCKMAN, ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:STOCKMAN
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 1:4438 N DAMEN AVE
Mailing Address - Street 2:4W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1718
Mailing Address - Country:US
Mailing Address - Phone:517-316-5366
Mailing Address - Fax:
Practice Address - Street 1:4438 N DAMEN AVE
Practice Address - Street 2:4W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1718
Practice Address - Country:US
Practice Address - Phone:517-316-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherITIN