Provider Demographics
NPI:1821461047
Name:ALONZO, ALICE (FNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:ALONZO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 GRIFFIN AVE
Mailing Address - Street 2:SUITES A
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-9104
Mailing Address - Country:US
Mailing Address - Phone:478-374-0020
Mailing Address - Fax:478-374-2937
Practice Address - Street 1:1112 PLAZA AVE STE B
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-9012
Practice Address - Country:US
Practice Address - Phone:478-448-8272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily