Provider Demographics
NPI:1518474451
Name:FODOR, ALISSA
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:FODOR
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 1:37 FRIEND ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-3068
Mailing Address - Country:US
Mailing Address - Phone:718-715-6608
Mailing Address - Fax:
Practice Address - Street 1:37 FRIEND ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-3068
Practice Address - Country:US
Practice Address - Phone:781-715-6608
Practice Address - Fax:617-529-6711
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-01
Last Update Date:2023-02-07
Deactivation Date:2023-01-30
Deactivation Code:
Reactivation Date:2023-02-07
Provider Licenses
StateLicense IDTaxonomies
MARN2281445164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty