Provider Demographics
NPI:1376976365
Name:DEARTH, ALYSSA ANN (MSN, APN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANN
Last Name:DEARTH
Suffix:
Gender:F
Credentials:MSN, APN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:151 W HIGH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1407
Practice Address - Country:US
Practice Address - Phone:815-705-1000
Practice Address - Fax:815-705-2709
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE (GROUP PTAN)
ILF400099927OtherMEDICARE (INDIVIDUAL PTAN)
IL209.010633OtherLICENSE