Healthcare Provider Details

I. General information

NPI: 1447182027
Provider Name (Legal Business Name): ALEXIS JORDAN MANDERY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2026
Last Update Date: 05/30/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 TOWER DR W STE 100
STILLWATER MN
55082-7512
US

IV. Provider business mailing address

1719 TOWER DR W STE 100
STILLWATER MN
55082-7512
US

V. Phone/Fax

Practice location:
  • Phone: 651-275-3000
  • Fax: 651-275-3027
Mailing address:
  • Phone: 651-275-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4053
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: