Provider Demographics
NPI:1922791425
Name:CHARBONNEAU, ALEXIS (NP)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5999
Mailing Address - Country:US
Mailing Address - Phone:315-801-8848
Mailing Address - Fax:
Practice Address - Street 1:13460 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13309-3531
Practice Address - Country:US
Practice Address - Phone:315-942-4391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY751282163W00000X
NY2458507363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse