Provider Demographics
NPI:1205454402
Name:WILLMORE, ALEXIS K
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:K
Last Name:WILLMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:K
Other - Last Name:WELSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-982-5864
Mailing Address - Fax:
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-983-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601010094363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical