Provider Demographics
NPI:1447725148
Name:WISNOSKI, ALEXANDRA KELLER (LAC)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:KELLER
Last Name:WISNOSKI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ALIKSANDRA
Other - Middle Name:
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:650 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2315
Mailing Address - Country:US
Mailing Address - Phone:631-566-2281
Mailing Address - Fax:
Practice Address - Street 1:650 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2315
Practice Address - Country:US
Practice Address - Phone:631-566-2281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006247171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist