Provider Demographics
NPI:1912303181
Name:VISCO, ALEXA GABRIELLE
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:GABRIELLE
Last Name:VISCO
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 1:83 NORTH AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5312
Mailing Address - Country:US
Mailing Address - Phone:802-318-1391
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010102746364SN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal