Healthcare Provider Details

I. General information

NPI: 1699959882
Provider Name (Legal Business Name): ALICIA LACHELLE WALLACE STEVENS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 S MAIN ST
POPLARVILLE MS
39470-3369
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-795-0659
  • Fax: 601-795-8639
Mailing address:
  • Phone: 601-795-0659
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPGY.2.TUL-MEDPD
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21723
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPGY.2.TUL-MEDPD
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21723
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: