Provider Demographics
NPI:1174602221
Name:WHITWELL, ALICIA R (NP)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:R
Last Name:WHITWELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-4002
Mailing Address - Country:US
Mailing Address - Phone:573-358-0801
Mailing Address - Fax:
Practice Address - Street 1:330 N STATE ST
Practice Address - Street 2:SUITE C
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-3052
Practice Address - Country:US
Practice Address - Phone:573-431-2829
Practice Address - Fax:573-431-7186
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO145117363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO421474909Medicaid
MO002013070Medicare ID - Type Unspecified
MO150050001Medicare PIN
MO421474909Medicaid
MO838143210Medicare PIN