Provider Demographics
NPI:1174953368
Name:THERRELL, ALICE LANE (RN, FNP-BC)
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:LANE
Last Name:THERRELL
Suffix:
Gender:F
Credentials:RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1198-1379
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95812
Mailing Address - Country:US
Mailing Address - Phone:530-304-7659
Mailing Address - Fax:
Practice Address - Street 1:4160 SUISUN VALLEY RD #132
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534
Practice Address - Country:US
Practice Address - Phone:530-304-7659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA797771163W00000X
CA23149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse