Provider Demographics
NPI:1841909744
Name:THEODOSIS, ALEXANDRA G (DNP, APNP, FNP-C)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:G
Last Name:THEODOSIS
Suffix:
Gender:F
Credentials:DNP, APNP, FNP-C
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:
Other - Last Name:IACOBUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:3235 S REGAL DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-4453
Mailing Address - Country:US
Mailing Address - Phone:630-337-4326
Mailing Address - Fax:
Practice Address - Street 1:1350 S SUNNY SLOPE RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-7060
Practice Address - Country:US
Practice Address - Phone:262-798-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13319-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13319-33OtherSTATE OF WISCONSIN DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES