Healthcare Provider Details

I. General information

NPI: 1366573966
Provider Name (Legal Business Name): ALEXA HELENA NIEHAUS P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 S MCINTIRE DR SUITE 350
BLOOMINGTON IN
47403-4221
US

IV. Provider business mailing address

PO BOX 1329
BLOOMINGTON IN
47402-1329
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-3277
  • Fax: 812-339-2934
Mailing address:
  • Phone: 812-353-3087
  • Fax: 812-353-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001464A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: