1174602221 NPI number — MRS. ALICIA R WHITWELL N.P.

Table of content: MRS. ALICIA R WHITWELL N.P. (NPI 1174602221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174602221 NPI number — MRS. ALICIA R WHITWELL N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITWELL
Provider First Name:
ALICIA
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174602221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
835 RIDGEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNE TERRE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63628-4002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-358-0801
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N STATE ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
DESLOGE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63601-3052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-431-2829
Provider Business Practice Location Address Fax Number:
573-431-7186
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  145117 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 421474909 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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