Healthcare Provider Details

I. General information

NPI: 1356929079
Provider Name (Legal Business Name): ALEXIS WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

409 CRYSTALWOOD COURT NW
CONCORD NC
28027-2200
US

IV. Provider business mailing address

409 CRYSTALWOOD COURT NW
CONCORD NC
28027-2200
US

V. Phone/Fax

Practice location:
  • Phone: 434-234-2184
  • Fax:
Mailing address:
  • Phone: 434-234-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: