Basic Information
| Provider Information | |||||||||
| NPI: | 1568113959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFF | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1751 BLASE NEMETH RD | ||||||||
| Address2: | |||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440774897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403438718 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12557 RAVENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440249009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402853568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2022 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APRN.CNP.0031863 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163W00000X | RN.456353 | OH | N | Nursing Service Providers | Registered Nurse |
No ID Information.