Provider Demographics
NPI:1922035906
Name:KING, ALICE LOUIETTA (ARNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:LOUIETTA
Last Name:KING
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:3000 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-8616
Practice Address - Country:US
Practice Address - Phone:941-406-9029
Practice Address - Fax:941-406-9028
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN7423363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN500028563OtherRR MEDICARE PIN
TN37066302OtherMEDICARE LEGACY GROUP
TN33454401Medicare PIN
TN37066302OtherMEDICARE LEGACY GROUP