Provider Demographics
NPI:1699959882
Name:WALLACE STEVENS, ALICIA LACHELLE (MD)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:LACHELLE
Last Name:WALLACE STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-795-0659
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1407 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-3369
Practice Address - Country:US
Practice Address - Phone:601-795-0659
Practice Address - Fax:601-795-8639
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPGY.2.TUL-MEDPD207R00000X, 208000000X
MS21723208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03205377Medicaid
MS302I115173Medicare PIN