Provider Demographics
NPI:1477003317
Name:GOSSETT, ALECIA I
Entity type:Individual
Prefix:
First Name:ALECIA
Middle Name:
Last Name:GOSSETT
Suffix:I
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:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:OK
Mailing Address - Zip Code:74730-0386
Mailing Address - Country:US
Mailing Address - Phone:580-434-5603
Mailing Address - Fax:
Practice Address - Street 1:308 W. SMISER
Practice Address - Street 2:
Practice Address - City:CALERA
Practice Address - State:OK
Practice Address - Zip Code:74730-0386
Practice Address - Country:US
Practice Address - Phone:580-434-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251K00000X251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1578691184Medicaid