Provider Demographics
NPI:1619711926
Name:CLEMENT, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:CLEMENT
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 1:1745 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 E HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT EISENHOWER
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-5841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4046133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered