Provider Demographics
NPI:1275803736
Name:ANDERSON, ALICIA MARY (RN)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARY
Last Name:ANDERSON
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 1:7 CARMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9428
Mailing Address - Country:US
Mailing Address - Phone:631-286-7460
Mailing Address - Fax:
Practice Address - Street 1:7 CARMAN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719-9428
Practice Address - Country:US
Practice Address - Phone:631-286-7460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334236-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse