Provider Demographics
NPI:1093059388
Name:BALLARD, ALICIA LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:LYNN
Last Name:BALLARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ALICIA
Other - Middle Name:LYNN
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:537 W. MAIN ST SUITE 102,
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846
Mailing Address - Country:US
Mailing Address - Phone:616-523-1010
Mailing Address - Fax:616-527-1131
Practice Address - Street 1:537 W. MAIN ST SUITE 102,
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846
Practice Address - Country:US
Practice Address - Phone:616-523-1010
Practice Address - Fax:616-527-1131
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019555207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery