Healthcare Provider Details

I. General information

NPI: 1295281681
Provider Name (Legal Business Name): ALICIA BRAND PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALICIA WISE BRAND

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD SUITE 1008
BATON ROUGE LA
70808-4300
US

IV. Provider business mailing address

9001 SUMMA AVE STE 346
BATON ROUGE LA
70809-3726
US

V. Phone/Fax

Practice location:
  • Phone: 225-766-0416
  • Fax:
Mailing address:
  • Phone: 225-769-3636
  • Fax: 225-771-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number303231
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: