Provider Demographics
NPI:1689457780
Name:WILKINSON, AALEXYZ MYCHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:AALEXYZ
Middle Name:MYCHELLE
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KAECI
Other - Middle Name:MYCHELLE
Other - Last Name:WILKINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1106 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3022
Mailing Address - Country:US
Mailing Address - Phone:458-658-4286
Mailing Address - Fax:
Practice Address - Street 1:940 TOWN CENTRE DR STE B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6165
Practice Address - Country:US
Practice Address - Phone:458-658-4286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27816225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty