Provider Demographics
NPI:1003119280
Name:FLETCHER, ALICIA G (ACNS-BC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:G
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-2434
Mailing Address - Fax:432-640-2428
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761
Practice Address - Country:US
Practice Address - Phone:432-640-2128
Practice Address - Fax:432-640-2428
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP119758364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365324801Medicaid