Healthcare Provider Details

I. General information

NPI: 1538782818
Provider Name (Legal Business Name): ALEXA KISSELBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 10/02/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

532 LORIMER ST APT 3B
BROOKLYN NY
11211-5991
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-2363
  • Fax:
Mailing address:
  • Phone: 516-660-6904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number702516
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383176
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: