Provider Demographics
NPI:1043864200
Name:STARE, ALYSSA JENINE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JENINE
Last Name:STARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 MIDDLE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-3126
Mailing Address - Country:US
Mailing Address - Phone:631-239-8262
Mailing Address - Fax:
Practice Address - Street 1:160 MIDDLE RD STE 1
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3126
Practice Address - Country:US
Practice Address - Phone:631-239-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031289225700000X
NY006235171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist