Healthcare Provider Details

I. General information

NPI: 1255790192
Provider Name (Legal Business Name): ALICIA BACCHUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2016
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 FORT WASHINGTON AVE
NEW YORK NY
10032
US

IV. Provider business mailing address

331 NEWMAN SPRINGS ROAD BLDG. 2, SUITE 220
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 707-344-2097
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF341946
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95003307
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15357100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: