Provider Demographics
NPI:1114544764
Name:FORTUNA, ALYSSA LYNN
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LYNN
Last Name:FORTUNA
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 1:210 ENCHANTED FRST N
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-5010
Mailing Address - Country:US
Mailing Address - Phone:716-912-5240
Mailing Address - Fax:
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-2100
Practice Address - Country:US
Practice Address - Phone:585-344-1345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY009183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program