Provider Demographics
NPI:1043616543
Name:WHITEHEAD, ALYSSA CAMERON (FNP)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CAMERON
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 N CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2054
Mailing Address - Country:US
Mailing Address - Phone:662-446-9012
Mailing Address - Fax:662-446-9432
Practice Address - Street 1:2750 N CHURCH AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2054
Practice Address - Country:US
Practice Address - Phone:662-446-9012
Practice Address - Fax:662-446-9432
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS396594YQJ8Medicare PIN