Provider Demographics
NPI:1306461645
Name:WHALEN, ALEXIS
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:WHALEN
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 1:3 SUNCREST DR # B
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12188-1321
Mailing Address - Country:US
Mailing Address - Phone:518-605-2179
Mailing Address - Fax:
Practice Address - Street 1:3 SUNCREST DR # B
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:NY
Practice Address - Zip Code:12188-1321
Practice Address - Country:US
Practice Address - Phone:518-605-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY763493-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse