MEDICARE: MRS. LARA J ALICEA FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	22569	SC

General Provider Information

NPI Number	:	1538624705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LARA J ALICEA FNP-C

Provider Business Mailing Address
First Line	:	2244 ASHLEY CROSSING DR UNIT 112
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29414-6082
Country	:	US
Telephone Number	:	951-445-8667
Fax Number	:

Provider Business Practice Location Address
First Line	:	2375 BAKER HOSPITAL BLVD
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-8233
Country	:	US
Telephone Number	:	843-744-2750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2019
Last Update Date	:	02/01/2019

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