Provider Demographics
NPI:1659569002
Name:SMITH, ALEXIA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:ALEXIA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15209 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9570
Mailing Address - Country:US
Mailing Address - Phone:269-781-9119
Mailing Address - Fax:269-789-4347
Practice Address - Street 1:15209 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-9570
Practice Address - Country:US
Practice Address - Phone:269-781-9119
Practice Address - Fax:269-789-4347
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI839833363LP0808X
MTMED-APRN-LIC-128631363LP0808X
MI4704252197363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704252197OtherLICENSE #