Healthcare Provider Details

I. General information

NPI: 1821461047
Provider Name (Legal Business Name): ALICE ALONZO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 PLAZA AVE STE B
EASTMAN GA
31023-9012
US

IV. Provider business mailing address

1111 GRIFFIN AVE SUITES A
EASTMAN GA
31023-9104
US

V. Phone/Fax

Practice location:
  • Phone: 478-448-8272
  • Fax:
Mailing address:
  • Phone: 478-374-0020
  • Fax: 478-374-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN149944
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: