Provider Demographics
NPI:1427573260
Name:WILSON, ALYSSA JORDAN (CRNP)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JORDAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:JORDAN
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 231396
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-1396
Mailing Address - Country:US
Mailing Address - Phone:334-213-8803
Mailing Address - Fax:
Practice Address - Street 1:212 ELLEN ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121
Practice Address - Country:US
Practice Address - Phone:205-625-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-12
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF06181825363LF0000X
AL1-141605363LF0000X, 363LP0808X
AL2017023808363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL241836Medicaid