Provider Demographics
NPI:1205429347
Name:GILLENWATER, ALEXIS E
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:E
Last Name:GILLENWATER
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 1:72 GILLENWATER DR APT 201
Mailing Address - Street 2:
Mailing Address - City:YAWKEY
Mailing Address - State:WV
Mailing Address - Zip Code:25573-2000
Mailing Address - Country:US
Mailing Address - Phone:304-549-9975
Mailing Address - Fax:
Practice Address - Street 1:72 GILLENWATER DR APT 201
Practice Address - Street 2:
Practice Address - City:YAWKEY
Practice Address - State:WV
Practice Address - Zip Code:25573-2000
Practice Address - Country:US
Practice Address - Phone:304-549-9975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker