Basic Information
| Provider Information | |||||||||
| NPI: | 1568793297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLOONE | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | GAMBLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GAMBLE | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 785 PRIMERA BLVD | ||||||||
| Address2: | SUITE# 1031 | ||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327462124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078348111 | ||||||||
| FaxNumber: | 4077081985 | ||||||||
| Practice Location | |||||||||
| Address1: | 785 PRIMERA BLVD | ||||||||
| Address2: | SUITE# 1031 | ||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327462124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078348111 | ||||||||
| FaxNumber: | 4077081985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | PA9105190 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 002015600 | 05 | FL | MEDICAID |