Provider Demographics
NPI:1780148270
Name:HEGSTROM, ALEXIS ANN
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ANN
Last Name:HEGSTROM
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 1:306 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49920-1200
Mailing Address - Country:US
Mailing Address - Phone:906-284-2801
Mailing Address - Fax:
Practice Address - Street 1:306 N 3RD ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL FALLS
Practice Address - State:MI
Practice Address - Zip Code:49920-1200
Practice Address - Country:US
Practice Address - Phone:906-284-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2887-19225200000X
MI5502005720225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant