Provider Demographics
NPI:1326553975
Name:WHITE, ALICIA RENEE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:RENEE
Last Name:WHITE
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 1:997 APPLECROSS DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8666
Mailing Address - Country:US
Mailing Address - Phone:859-309-3183
Mailing Address - Fax:
Practice Address - Street 1:1500 LEESTOWN RD STE 338
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-2047
Practice Address - Country:US
Practice Address - Phone:859-309-3183
Practice Address - Fax:859-309-3183
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY107678225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
107678OtherKENTUCKY