Healthcare Provider Details

I. General information

NPI: 1053177394
Provider Name (Legal Business Name): ALEXIA BOUMIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 03/23/2024
Certification Date: 03/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 QUEENS BLVD STE 400
FOREST HILLS NY
11375-7211
US

IV. Provider business mailing address

PO BOX 639295
CINCINNATI OH
45263-9295
US

V. Phone/Fax

Practice location:
  • Phone: 646-722-7610
  • Fax:
Mailing address:
  • Phone: 248-266-4200
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF311504-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: