Healthcare Provider Details

I. General information

NPI: 1235546029
Provider Name (Legal Business Name): ALEXA MEZERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 N BROAD ST
ELKHORN WI
53121-1104
US

IV. Provider business mailing address

3268 BRIAR CREST DR
JANESVILLE WI
53546-9603
US

V. Phone/Fax

Practice location:
  • Phone: 262-723-4963
  • Fax:
Mailing address:
  • Phone: 608-445-2258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5051-27
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057003908
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: