Provider Demographics
NPI:1891125001
Name:HUMPHREY, ALEXISA M (IDMT)
Entity Type:Individual
Prefix:MS
First Name:ALEXISA
Middle Name:M
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-4156
Mailing Address - Country:US
Mailing Address - Phone:702-427-1782
Mailing Address - Fax:
Practice Address - Street 1:225 VON KARMAN RD
Practice Address - Street 2:BLDG 225
Practice Address - City:ARNOLD AFB
Practice Address - State:TN
Practice Address - Zip Code:37389
Practice Address - Country:US
Practice Address - Phone:931-454-5365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians