Healthcare Provider Details

I. General information

NPI: 1508605197
Provider Name (Legal Business Name): ALEXA WURM PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 12/05/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 RICKER RD
SALEM IL
62881-4263
US

IV. Provider business mailing address

19708 US HIGHWAY 50
CARLYLE IL
62231-2328
US

V. Phone/Fax

Practice location:
  • Phone: 618-975-4621
  • Fax:
Mailing address:
  • Phone: 618-975-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041508434
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.031183
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: