Provider Demographics
NPI:1942819545
Name:HAISLEY, ALICIA (ANP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:HAISLEY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:HAISLEY-MUHAMMAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:504 VILLAGE PT
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-5100
Practice Address - Country:US
Practice Address - Phone:404-275-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF07200719364SF0001X
GARN230695363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health