Provider Demographics
NPI:1922266188
Name:CLINTON, ALEXANDRA EVANGELINE (LAC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:EVANGELINE
Last Name:CLINTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 COVEY CIR N
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4698
Mailing Address - Country:US
Mailing Address - Phone:815-914-1179
Mailing Address - Fax:
Practice Address - Street 1:6645 N SOCRUM LOOP RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4182
Practice Address - Country:US
Practice Address - Phone:863-853-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2577171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist