Provider Demographics
NPI:1588036735
Name:DUBOSE, ALICIA (NP)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:
Last Name:DUBOSE
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 1:1715 23RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301
Mailing Address - Country:US
Mailing Address - Phone:607-696-6736
Mailing Address - Fax:
Practice Address - Street 1:1715 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3104
Practice Address - Country:US
Practice Address - Phone:607-696-6736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866633363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner