Healthcare Provider Details

I. General information

NPI: 1699617647
Provider Name (Legal Business Name): ALEXANDRA MOUANNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEXY MOUANNES

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3078 BROADWAY UNIT 203
SAN DIEGO CA
92102-2348
US

IV. Provider business mailing address

3078 BROADWAY UNIT 203
SAN DIEGO CA
92102-2348
US

V. Phone/Fax

Practice location:
  • Phone: 763-226-1407
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number25656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: