Healthcare Provider Details

I. General information

NPI: 1649185133
Provider Name (Legal Business Name): ALEXIS MAE GLOVER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11731 POINTE PL
ROSWELL GA
30076-4636
US

IV. Provider business mailing address

40 OLD FRIENDSHIP LN
DAWSONVILLE GA
30534-7365
US

V. Phone/Fax

Practice location:
  • Phone: 770-284-3150
  • Fax:
Mailing address:
  • Phone: 678-897-8732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14128
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: