Basic Information
| Provider Information | |||||||||
| NPI: | 1255884359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 102 HOSPITALITY DR | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638019382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2016 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 2019000490 | MO | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207Q00000X | 2016021991 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200071642 | 05 | MO | MEDICAID |