Provider Demographics
NPI:1588395859
Name:ANDERSON, ALEXIS DESIRAE' (FNP-C)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:DESIRAE'
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1569 REDCOAT DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-2823
Mailing Address - Country:US
Mailing Address - Phone:314-305-0329
Mailing Address - Fax:
Practice Address - Street 1:3960 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3204
Practice Address - Country:US
Practice Address - Phone:314-652-0100
Practice Address - Fax:314-531-1768
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022022685363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily