Provider Demographics
NPI:1124480405
Name:LICON, ALLEXA
Entity type:Individual
Prefix:
First Name:ALLEXA
Middle Name:
Last Name:LICON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALLEXA
Other - Middle Name:
Other - Last Name:HAMMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 W BELTLINE HWY STE 200
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-2319
Practice Address - Country:US
Practice Address - Phone:082-872-4346
Practice Address - Fax:608-287-2182
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77126-20207RC0000X
WI77126207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease