Provider Demographics
NPI:1104638584
Name:GOOD, ALEXA KYLYN MICHELLE (OTS)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:KYLYN MICHELLE
Last Name:GOOD
Suffix:
Gender:F
Credentials:OTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 KINKEAD AVE APT 235
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-1507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7006 CHAD COLLEY BLVD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-6024
Practice Address - Country:US
Practice Address - Phone:479-401-6013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program