Provider Demographics
NPI:1083098107
Name:SUNDSTROM, ALYSSA ANN (CPNP)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANN
Last Name:SUNDSTROM
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:A
Other - Last Name:GUERTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:508-852-1022
Practice Address - Street 1:630 PLANTATION ST
Practice Address - Street 2:WOT 12TH FL
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2038
Practice Address - Country:US
Practice Address - Phone:508-852-8570
Practice Address - Fax:508-852-1022
Is Sole Proprietor?:No
Enumeration Date:2015-07-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN269516363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics