Provider Demographics
NPI:1205163169
Name:RENDON, ALICIA M (NP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:RENDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 HICKORY CREEK LN
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34602-6287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3224 HICKORY CREEK LN
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34602-6287
Practice Address - Country:US
Practice Address - Phone:239-919-6568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9438023363LA2200X, 363LA2200X
OHCOA.11079-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066367Medicaid
OH0066367Medicaid