Provider Demographics
NPI:1780787598
Name:FOSSETT, ALICIA JOHNSON
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:JOHNSON
Last Name:FOSSETT
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:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:LANGSTON
Mailing Address - State:AL
Mailing Address - Zip Code:35755-0057
Mailing Address - Country:US
Mailing Address - Phone:256-259-1474
Mailing Address - Fax:
Practice Address - Street 1:508 GREGORY ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-4239
Practice Address - Country:US
Practice Address - Phone:256-259-1774
Practice Address - Fax:256-259-0761
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist