Provider Demographics
NPI:1982156014
Name:WATKINS, ALEXANDRA (LAC, MSTOM)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4447 N HAMLIN AVE
Mailing Address - Street 2:#3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4447 N HAMLIN AVE
Practice Address - Street 2:#3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5940
Practice Address - Country:US
Practice Address - Phone:773-628-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL189.001185171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist