Healthcare Provider Details

I. General information

NPI: 1710549522
Provider Name (Legal Business Name): ALEXIS WILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6244 EL CAJON BLVD STE 14
SAN DIEGO CA
92115-3918
US

IV. Provider business mailing address

8755 AERO DR STE 230
SAN DIEGO CA
92123-1750
US

V. Phone/Fax

Practice location:
  • Phone: 619-640-3266
  • Fax:
Mailing address:
  • Phone: 858-256-2180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number98418
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: