Basic Information
Provider Information | |||||||||
NPI: | 1396477675 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MYERS | ||||||||
FirstName: | ALEXANDRA | ||||||||
MiddleName: | RAE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STREU | ||||||||
OtherFirstName: | ALEXANDRA | ||||||||
OtherMiddleName: | RAE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2600 MARBLE AVE NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871062058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052724475 | ||||||||
FaxNumber: | 5052728088 | ||||||||
Practice Location | |||||||||
Address1: | 2600 MARBLE AVE NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871062058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052724475 | ||||||||
FaxNumber: | 5052728088 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2022 | ||||||||
LastUpdateDate: | 06/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 63729 | NM | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.