Provider Demographics
NPI:1699233874
Name:POWELL, ALEXA
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:POWELL
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 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:867-714-8205
Mailing Address - Fax:586-771-7960
Practice Address - Street 1:130 TOWN CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1744
Practice Address - Country:US
Practice Address - Phone:248-740-0670
Practice Address - Fax:248-740-0668
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily