Provider Demographics
NPI:1053152496
Name:NIVAUD, ALEXIS KIM (OD)
Entity type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:KIM
Last Name:NIVAUD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20094 KENWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5404
Mailing Address - Country:US
Mailing Address - Phone:952-469-3937
Mailing Address - Fax:
Practice Address - Street 1:20094 KENWOOD TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5404
Practice Address - Country:US
Practice Address - Phone:952-469-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist