Provider Demographics
NPI:1740761253
Name:SEO, ALICE
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:SEO
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 1:7124 162ND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-1640
Practice Address - Country:US
Practice Address - Phone:267-273-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2024-07-23
Deactivation Date:2024-06-28
Deactivation Code:
Reactivation Date:2024-07-12
Provider Licenses
StateLicense IDTaxonomies
PANPPA062415363LF0000X
183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No183700000XPharmacy Service ProvidersPharmacy Technician