=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255067377
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXA NITKA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2022
-----------------------------------------------------
Last Update Date | 07/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MEDICAL PLAZA DRIVEWAY STE 430
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-794-7274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 MAIN ST APT 214
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90291-5233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-912-2537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 170300000X
-----------------------------------------------------
Taxonomy Name | Genetic Counselor (M.S.)
-----------------------------------------------------
License Number | GC001617
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------