Provider Demographics
NPI:1053812289
Name:FOBARE, ALEXIS ROSE
Entity type:Individual
Prefix:MISS
First Name:ALEXIS
Middle Name:ROSE
Last Name:FOBARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:MOHAWK
Mailing Address - State:NY
Mailing Address - Zip Code:13407-1530
Mailing Address - Country:US
Mailing Address - Phone:315-868-0205
Mailing Address - Fax:
Practice Address - Street 1:53 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MOHAWK
Practice Address - State:NY
Practice Address - Zip Code:13407-1530
Practice Address - Country:US
Practice Address - Phone:315-868-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator