Provider Demographics
NPI:1265633697
Name:LOVELACE, ALICIA S
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:S
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 BLAZING STAR RD
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540
Mailing Address - Country:US
Mailing Address - Phone:706-273-8813
Mailing Address - Fax:
Practice Address - Street 1:630 BLAZING STAR RD
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540
Practice Address - Country:US
Practice Address - Phone:706-273-8813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPT 001251174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist