Provider Demographics
NPI:1871171975
Name:PETERSON, ALEXA RENEE (DO)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:RENEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 LIGHTHOUSE PL
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5015
Practice Address - Country:US
Practice Address - Phone:931-502-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN5784207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program