Provider Demographics
NPI:1538931548
Name:MARTIN, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 CHATEAU DR
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-4100
Mailing Address - Country:US
Mailing Address - Phone:678-699-3489
Mailing Address - Fax:
Practice Address - Street 1:58 CHATEAU DR
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-4100
Practice Address - Country:US
Practice Address - Phone:678-699-3489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1036376163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse