Healthcare Provider Details

I. General information

NPI: 1497228225
Provider Name (Legal Business Name): ALEXA MAMMEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11830 W MARKET PL
FULTON MD
20759-2431
US

IV. Provider business mailing address

11830 W MARKET PL STE N-Q
FULTON MD
20759-2431
US

V. Phone/Fax

Practice location:
  • Phone: 667-205-4290
  • Fax:
Mailing address:
  • Phone: 248-918-9508
  • Fax:

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 State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number28647
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: