Provider Demographics
NPI:1417372616
Name:FASTNACHT, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:FASTNACHT
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 1:27 ROULSTON RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1210
Mailing Address - Country:US
Mailing Address - Phone:603-870-0078
Mailing Address - Fax:603-870-8134
Practice Address - Street 1:27 ROULSTON RD
Practice Address - Street 2:UNIT 1
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-1210
Practice Address - Country:US
Practice Address - Phone:603-870-0078
Practice Address - Fax:603-870-8134
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2353225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist