MEDICARE: ALEXIS MARIE HENSHILWOOD N/A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker
2	376J00000X	Homemaker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	222410268	OTHER	UT	DRIVERS LICENSE

General Provider Information

NPI Number	:	1043949373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS MARIE HENSHILWOOD N/A

Provider Business Mailing Address
First Line	:	628 N 1360 W
Second Line	:
City	:	CLEARFIELD
State	:	UT
Zip	:	84015-6501
Country	:	US
Telephone Number	:	385-427-4030
Fax Number	:

Provider Business Practice Location Address
First Line	:	2486 S DOUGLAS ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3185
Country	:	US
Telephone Number	:	385-427-4030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2022
Last Update Date	:	09/19/2023

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