Provider Demographics
NPI:1790490993
Name:HENRIE, ALEXA JADE
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:JADE
Last Name:HENRIE
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 1:2630 E STRINGHAM AVE APT A224
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 S 2000 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5821
Practice Address - Country:US
Practice Address - Phone:801-581-8049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program