Provider Demographics
NPI:1265265581
Name:PRY, ALICIA (CPHT, CHW-C)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:PRY
Suffix:
Gender:F
Credentials:CPHT, CHW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1457 E LINDBERG ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2418
Mailing Address - Country:US
Mailing Address - Phone:417-773-8997
Mailing Address - Fax:
Practice Address - Street 1:2650 W KEARNEY ST STE 116
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2055
Practice Address - Country:US
Practice Address - Phone:417-865-1547
Practice Address - Fax:417-862-2571
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018012435183700000X
MO17294172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No183700000XPharmacy Service ProvidersPharmacy Technician