Provider Demographics
NPI:1578261962
Name:BAKER, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BAKER
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 1:1100 HWY 35 # 1033
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3542
Mailing Address - Country:US
Mailing Address - Phone:732-228-8703
Mailing Address - Fax:732-231-5081
Practice Address - Street 1:295 BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6942
Practice Address - Country:US
Practice Address - Phone:732-272-1585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32WG02086200335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier