Provider Demographics
NPI:1356212708
Name:ELLIS, ALEXANDRA
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:ELLIS
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 1:3875 EAGLE PASS
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49690-8609
Mailing Address - Country:US
Mailing Address - Phone:231-922-4850
Mailing Address - Fax:231-935-3696
Practice Address - Street 1:105 HALL ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2288
Practice Address - Country:US
Practice Address - Phone:231-922-4850
Practice Address - Fax:231-935-3696
Is Sole Proprietor?:No
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program