Provider Demographics
NPI:1457111361
Name:SANDERSON, ALICIA RAE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:RAE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 N SLATON ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0037
Mailing Address - Country:US
Mailing Address - Phone:907-669-0192
Mailing Address - Fax:
Practice Address - Street 1:700 E RAILROAD AVE STE 1
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8136
Practice Address - Country:US
Practice Address - Phone:907-947-7258
Practice Address - Fax:907-615-3002
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK220619225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist