Healthcare Provider Details

I. General information

NPI: 1245172261
Provider Name (Legal Business Name): MIA ALEXIS WILBORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

2651 SAFFRON LN APT 27
BEAVERCREEK OH
45431-2378
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-8761
  • Fax:
Mailing address:
  • Phone: 808-754-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0401420212
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: