Basic Information
| Provider Information | |||||||||
| NPI: | 1740201763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARLEY | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | GUTKNECHT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 E ST SE UNIT 312 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200033983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048586519 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3020 14TH ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200096865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027454300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 02/18/2019 | ||||||||
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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 | 208000000X | MD045889 | DC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1901580 | 05 | LA | MEDICAID |