Provider Demographics
NPI:1114662228
Name:DANTZLER, ALICIA (RN)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DANTZLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 FAIRFAX PL
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5808
Mailing Address - Country:US
Mailing Address - Phone:315-368-6746
Mailing Address - Fax:
Practice Address - Street 1:929 YORK ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3929
Practice Address - Country:US
Practice Address - Phone:315-368-6746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY737091-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY156002667Medicaid