Provider Demographics
NPI:1760158489
Name:MCDANIEL, ALEXANDREA NICHOLE
Entity Type:Individual
Prefix:
First Name:ALEXANDREA
Middle Name:NICHOLE
Last Name:MCDANIEL
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 1:12046 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-8601
Mailing Address - Country:US
Mailing Address - Phone:269-425-0103
Mailing Address - Fax:
Practice Address - Street 1:12046 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-8601
Practice Address - Country:US
Practice Address - Phone:269-425-0103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant