Healthcare Provider Details

I. General information

NPI: 1538824156
Provider Name (Legal Business Name): ALEXANDRA CONWAY MS, LAT, ATC, EMT-B
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA IAKIMENKO MS, LAT, ATC, EMT-B

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W OLNEY AVE
PHILADELPHIA PA
19141-1108
US

IV. Provider business mailing address

6204 AVENEL BLVD
NORTH WALES PA
19454-3959
US

V. Phone/Fax

Practice location:
  • Phone: 215-951-1519
  • Fax:
Mailing address:
  • Phone: 484-716-0593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT008192
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number0912212
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: