Provider Demographics
NPI:1558124925
Name:ELLSWORTH, ALYSSA ANNE J (APRN)
Entity Type:Individual
Prefix:
First Name:ALYSSA ANNE
Middle Name:J
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 S 1400 E
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-3091
Mailing Address - Country:US
Mailing Address - Phone:801-717-7710
Mailing Address - Fax:
Practice Address - Street 1:826 N 100 E STE 7
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1241
Practice Address - Country:US
Practice Address - Phone:801-717-7710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6943430-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily