Provider Demographics
NPI:1770988008
Name:ALEXIS, WANDA (MSED)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:ALEXIS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 NEW YORK AVE
Mailing Address - Street 2:APT. 2A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-1657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1408 NEW YORK AVE
Practice Address - Street 2:APT. 2A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-1657
Practice Address - Country:US
Practice Address - Phone:917-304-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist