Provider Demographics
NPI:1073142816
Name:PROVOST, ALISHA
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISHA
Other - Middle Name:
Other - Last Name:COPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 SAINT ELIZABETH BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1281
Mailing Address - Country:US
Mailing Address - Phone:618-256-9355
Mailing Address - Fax:618-206-2332
Practice Address - Street 1:3 SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-1281
Practice Address - Country:US
Practice Address - Phone:618-256-9355
Practice Address - Fax:618-206-2332
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022032506208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice