Healthcare Provider Details

I. General information

NPI: 1780575456
Provider Name (Legal Business Name): SHAWNTRIA ALEXANDER AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 WHITE PLAINS RD
BRONX NY
10470-1136
US

IV. Provider business mailing address

301 S CORDER RD APT 216
WARNER ROBINS GA
31088-5727
US

V. Phone/Fax

Practice location:
  • Phone: 646-289-5356
  • Fax:
Mailing address:
  • Phone: 229-591-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAG05250017
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: