Provider Demographics
NPI:1356318620
Name:RESTIVO, ALICIA RUTHERFORD (NP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:RUTHERFORD
Last Name:RESTIVO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24986 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-6602
Mailing Address - Country:US
Mailing Address - Phone:225-667-9657
Mailing Address - Fax:
Practice Address - Street 1:INFIRMARY RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70803-0001
Practice Address - Country:US
Practice Address - Phone:225-578-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04303363LF0000X
LARN096234363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1465861Medicaid
P99461Medicare UPIN
LA4C837CC16Medicare ID - Type Unspecified