Provider Demographics
NPI:1891512877
Name:FANGIO, ALEXA
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:FANGIO
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 1:25 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-3507
Mailing Address - Country:US
Mailing Address - Phone:570-808-3653
Mailing Address - Fax:570-808-3554
Practice Address - Street 1:25 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3507
Practice Address - Country:US
Practice Address - Phone:570-808-3653
Practice Address - Fax:570-808-3554
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSL002615235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist