Provider Demographics
NPI:1881274785
Name:PRIDDY, ALEXIS RENEE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:RENEE
Last Name:PRIDDY
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 1:5114 N GLEN PARK PLACE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4686
Mailing Address - Country:US
Mailing Address - Phone:309-683-5600
Mailing Address - Fax:309-683-5607
Practice Address - Street 1:5114 N GLEN PARK PLACE RD STE 110
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4686
Practice Address - Country:US
Practice Address - Phone:309-683-5600
Practice Address - Fax:309-683-5607
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036172706208000000X, 207R00000X
GA13452208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program