Provider Demographics
NPI:1205557006
Name:ALEXIS, KERONNE N/A (ADVANCE PRACTICE RN)
Entity type:Individual
Prefix:
First Name:KERONNE
Middle Name:N/A
Last Name:ALEXIS
Suffix:
Gender:F
Credentials:ADVANCE PRACTICE RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 SW 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-2731
Mailing Address - Country:US
Mailing Address - Phone:689-221-2774
Mailing Address - Fax:
Practice Address - Street 1:870 SW 64TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-2731
Practice Address - Country:US
Practice Address - Phone:689-221-2774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL143506101YM0800X, 103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling