Healthcare Provider Details

I. General information

NPI: 1215512686
Provider Name (Legal Business Name): ALICIA MINGO LPN, CCHC, CBS, CBE,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 DEAN RD APT 2112
SHREVEPORT LA
71118-2851
US

IV. Provider business mailing address

2400 TEXAS AVE UNIT 38602
SHREVEPORT LA
71133-5116
US

V. Phone/Fax

Practice location:
  • Phone: 318-219-6640
  • Fax:
Mailing address:
  • Phone: 318-219-6640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number20160175
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: