Healthcare Provider Details

I. General information

NPI: 1275266272
Provider Name (Legal Business Name): ALEXIS AMBROSIA SCUDDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 06/20/2023
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 W SHAW AVE STE 201
FRESNO CA
93711-3519
US

IV. Provider business mailing address

4667 N LORNA AVE
FRESNO CA
93705-1128
US

V. Phone/Fax

Practice location:
  • Phone: 559-271-3096
  • Fax:
Mailing address:
  • Phone: 559-981-4632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: