Healthcare Provider Details

I. General information

NPI: 1881274785
Provider Name (Legal Business Name): ALEXIS RENEE PRIDDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 N GLEN PARK PLACE RD STE 110
PEORIA IL
61614-4686
US

IV. Provider business mailing address

5114 N GLEN PARK PLACE RD STE 110
PEORIA IL
61614-4686
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-5600
  • Fax: 309-683-5607
Mailing address:
  • Phone: 309-683-5600
  • Fax: 309-683-5607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036172706
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036172706
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13452
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: