Provider Demographics
NPI:1629739818
Name:BERRY-KAHO, ALICIA R (LPN)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:R
Last Name:BERRY-KAHO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2252
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-2252
Mailing Address - Country:US
Mailing Address - Phone:601-451-5018
Mailing Address - Fax:601-451-5018
Practice Address - Street 1:90 AVENDALE ROAD
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-451-5018
Practice Address - Fax:601-451-5018
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS320763164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse