Provider Demographics
NPI:1255732988
Name:CHAMPAGNE, ALICIA (MED, LAT, ATC)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 2ND AVE N
Mailing Address - Street 2:STOP 9013
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-6060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2751 2ND AVE N
Practice Address - Street 2:STOP 9013
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-6060
Practice Address - Country:US
Practice Address - Phone:701-777-0723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND558-142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer