Healthcare Provider Details

I. General information

NPI: 1649996208
Provider Name (Legal Business Name): ANGELICA ALICEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGIE ALICEA

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6804 HALLARD CT
FREDERICK MD
21703-2871
US

IV. Provider business mailing address

6804 HALLARD CT
FREDERICK MD
21703-2871
US

V. Phone/Fax

Practice location:
  • Phone: 301-676-5256
  • Fax:
Mailing address:
  • Phone: 301-676-5256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: