Provider Demographics
NPI:1760822043
Name:HEAD, ALACEA L (RN)
Entity Type:Individual
Prefix:
First Name:ALACEA
Middle Name:L
Last Name:HEAD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 34TH ST
Mailing Address - Street 2:APT 6E
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8572
Mailing Address - Country:US
Mailing Address - Phone:907-888-4524
Mailing Address - Fax:307-332-0131
Practice Address - Street 1:1150 34TH ST
Practice Address - Street 2:APT 6E
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8572
Practice Address - Country:US
Practice Address - Phone:907-888-4524
Practice Address - Fax:307-332-0131
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-59335163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105726000Medicaid