Healthcare Provider Details

I. General information

NPI: 1487188256
Provider Name (Legal Business Name): ALICIA FAULK NICKLAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 GENEVIEVE DR
LAFAYETTE LA
70503-4811
US

IV. Provider business mailing address

104 GENEVIEVE DR
LAFAYETTE LA
70503-4811
US

V. Phone/Fax

Practice location:
  • Phone: 337-984-0110
  • Fax: 337-981-7210
Mailing address:
  • Phone: 337-984-0110
  • Fax: 337-981-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP09172
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: