Provider Demographics
NPI:1164828513
Name:BECKER, ALISSA (CRNP)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:19725 ALLEN RD
Mailing Address - Street 2:STE 102
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19725 ALLEN RD
Practice Address - Street 2:STE 102
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1090
Practice Address - Country:US
Practice Address - Phone:734-479-7246
Practice Address - Fax:734-479-0214
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2017-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286259363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health