Provider Demographics
NPI:1679756456
Name:MOSVOLD, ALEXIS M
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:M
Last Name:MOSVOLD
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 1:409 MARQUETTE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4719
Mailing Address - Country:US
Mailing Address - Phone:502-296-5009
Mailing Address - Fax:
Practice Address - Street 1:409 MARQUETTE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4719
Practice Address - Country:US
Practice Address - Phone:502-296-5009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0480171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor