Provider Demographics
NPI:1609766112
Name:BROCKMAN, ALEXANDRA HART
Entity type:Individual
Prefix:MRS
First Name:ALEXANDRA
Middle Name:HART
Last Name:BROCKMAN
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 1:457 STEPHENSON ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4427
Mailing Address - Country:US
Mailing Address - Phone:561-385-9602
Mailing Address - Fax:
Practice Address - Street 1:457 STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4427
Practice Address - Country:US
Practice Address - Phone:561-385-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207486390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program