Healthcare Provider Details

I. General information

NPI: 1023913910
Provider Name (Legal Business Name): ALEXIS EDEN LOUTHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 MALIBU DR SE
LACEY WA
98503-1366
US

IV. Provider business mailing address

614 MALIBU DR SE
LACEY WA
98503-1366
US

V. Phone/Fax

Practice location:
  • Phone: 970-620-5593
  • Fax:
Mailing address:
  • Phone: 970-620-5593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP70012073
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: