Healthcare Provider Details

I. General information

NPI: 1245172261
Provider Name (Legal Business Name): MIA ALEXIS WILBORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

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

600 W ST NW # 2005
WASHINGTON DC
20059-1022
US

IV. Provider business mailing address

13103 ROCKPOINTE CT
CLIFTON VA
20124-0961
US

V. Phone/Fax

Practice location:
  • Phone: 202-806-0007
  • Fax:
Mailing address:
  • Phone: 808-754-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: