Provider Demographics
NPI:1306692934
Name:TAVARES, ALEXA NICOLE (DC)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:NICOLE
Last Name:TAVARES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ALEXA
Other - Middle Name:NICOLE
Other - Last Name:TAVARES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:820 ELMWOOD AVE PO BOX 72758
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1196 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-3716
Practice Address - Country:US
Practice Address - Phone:401-461-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00721111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor