Provider Demographics
NPI:1770016636
Name:MENILLO, ALEXANDRA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:MARIE
Last Name:MENILLO
Suffix:
Gender:F
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:9679 BAY HARBOR CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-5723
Mailing Address - Country:US
Mailing Address - Phone:201-983-7744
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 4200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2559
Practice Address - Country:US
Practice Address - Phone:616-267-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51010261482080P0202X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology