Provider Demographics
NPI:1164041125
Name:KEYSOR, ALISSA R (LPN)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:R
Last Name:KEYSOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 PLYMOUTH ST APT A
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:44865-1027
Mailing Address - Country:US
Mailing Address - Phone:419-515-9873
Mailing Address - Fax:
Practice Address - Street 1:475 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1501
Practice Address - Country:US
Practice Address - Phone:419-419-5705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH164075164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse