Provider Demographics
NPI:1063610434
Name:EASLEY, ALICIA LA VONNE (MD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:LA VONNE
Last Name:EASLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 W SUNSET BLVD
Mailing Address - Street 2:MS #94
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6062
Mailing Address - Country:US
Mailing Address - Phone:323-361-6177
Mailing Address - Fax:323-361-8106
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS #94
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-6177
Practice Address - Fax:323-361-8106
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70767208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A707670Medicaid