Provider Demographics
NPI:1033745971
Name:VENCKUS, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:VENCKUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 E HAMPDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-2795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E HAMPDEN AVE STE 400
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2886
Practice Address - Country:US
Practice Address - Phone:303-789-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-22
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007776363A00000X
390200000X
CO0007885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty