Healthcare Provider Details

I. General information

NPI: 1013417856
Provider Name (Legal Business Name): ALEXANDRIA MULVANEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRIA STAKER

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 MANGO MULLET DR APT 1
WEST LIBERTY WV
26074-1106
US

IV. Provider business mailing address

42 MANGO MULLET DR APT 1
WEST LIBERTY WV
26074-1106
US

V. Phone/Fax

Practice location:
  • Phone: 740-868-7790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: