Provider Demographics
NPI:1487188256
Name:NICKLAS, ALICIA FAULK (NP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:FAULK
Last Name:NICKLAS
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 1:104 GENEVIEVE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4811
Mailing Address - Country:US
Mailing Address - Phone:337-984-0110
Mailing Address - Fax:337-981-7210
Practice Address - Street 1:104 GENEVIEVE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4811
Practice Address - Country:US
Practice Address - Phone:337-984-0110
Practice Address - Fax:337-981-7210
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09172363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics