Provider Demographics
NPI:1497370852
Name:BALTUSEVICH, ALYSSA ROSE (CRNA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ROSE
Last Name:BALTUSEVICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:ROSE
Other - Last Name:JIMERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:217-788-3000
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3000
Practice Address - Fax:217-757-2021
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021389367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041437823OtherRN LICENSE