Provider Demographics
NPI:1275781817
Name:WALTY, ALYCIA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALYCIA
Middle Name:ANN
Last Name:WALTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7089
Mailing Address - Country:US
Mailing Address - Phone:606-287-7104
Mailing Address - Fax:606-287-4409
Practice Address - Street 1:211 US HIGHWAY 421 S
Practice Address - Street 2:
Practice Address - City:MC KEE
Practice Address - State:KY
Practice Address - Zip Code:40447-9425
Practice Address - Country:US
Practice Address - Phone:606-287-7104
Practice Address - Fax:606-287-4409
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD451752208000000X
NJ25MA08433100208000000X
KY42455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100087740Medicaid
KY7100087740Medicaid
KY181822Medicare Oscar/Certification