Healthcare Provider Details

I. General information

NPI: 1285298315
Provider Name (Legal Business Name): ALEXANDRA MARIE LIZON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 5TH ST
MODESTO CA
95351-3316
US

IV. Provider business mailing address

605 5TH ST
MODESTO CA
95351-3316
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-0718
  • Fax:
Mailing address:
  • Phone: 209-341-0718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: