Provider Demographics
NPI:1932784105
Name:KELLY, ALYXANDREA MARIE (PMHNP)
Entity type:Individual
Prefix:
First Name:ALYXANDREA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 BROCK ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3617
Mailing Address - Country:US
Mailing Address - Phone:231-970-0460
Mailing Address - Fax:
Practice Address - Street 1:777 CRAIG RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7276
Practice Address - Country:US
Practice Address - Phone:231-970-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313495163W00000X
MO2024000884363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse