Provider Demographics
NPI:1962471987
Name:MORNEAULT, ALICIA R (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:R
Last Name:MORNEAULT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:R
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:417A RACETRACK RD NW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-4600
Mailing Address - Country:US
Mailing Address - Phone:850-863-5990
Mailing Address - Fax:850-862-0041
Practice Address - Street 1:417A RACETRACK RD NW
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-4600
Practice Address - Country:US
Practice Address - Phone:850-863-5990
Practice Address - Fax:850-862-0041
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291883800Medicaid
FL291883800Medicaid
FLU3193ZMedicare ID - Type Unspecified