Provider Demographics
NPI:1134691223
Name:COLEY, ALICIA (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:COLEY
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-8134
Mailing Address - Country:US
Mailing Address - Phone:757-277-8268
Mailing Address - Fax:
Practice Address - Street 1:1531 AMBERLEY FOREST RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-4706
Practice Address - Country:US
Practice Address - Phone:757-277-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12011110851744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management