Provider Demographics
NPI:1679967772
Name:WILSON, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:
Other - Last Name:MUNRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2761
Mailing Address - Country:US
Mailing Address - Phone:303-388-4461
Mailing Address - Fax:303-270-2174
Practice Address - Street 1:1400 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-2761
Practice Address - Country:US
Practice Address - Phone:303-388-4461
Practice Address - Fax:303-270-2174
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21110475133NN1002X
CO993180133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21110475OtherCERTIFIED DIABETES EDUCATOR
CO993180OtherREGISTERD DIETICIAN
CO2008OtherINTERNSHIP CERTIFICATE DIETETICS