Provider Demographics
NPI:1336543305
Name:BRISTER, ALICIA (CFNP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BRISTER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 POWELL GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JAYESS
Mailing Address - State:MS
Mailing Address - Zip Code:39641-3610
Mailing Address - Country:US
Mailing Address - Phone:601-455-7234
Mailing Address - Fax:
Practice Address - Street 1:914 SUMRALL RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2652
Practice Address - Country:US
Practice Address - Phone:601-731-1470
Practice Address - Fax:601-731-1474
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily