Provider Demographics
NPI:1104317825
Name:ALEXANDER, ANISSA QUANSHA
Entity type:Individual
Prefix:
First Name:ANISSA
Middle Name:QUANSHA
Last Name:ALEXANDER
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 1:2259 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7912
Mailing Address - Country:US
Mailing Address - Phone:662-931-6468
Mailing Address - Fax:
Practice Address - Street 1:2259 HICKORY DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7912
Practice Address - Country:US
Practice Address - Phone:662-931-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver