Provider Demographics
NPI:1588004972
Name:CHAFE, ALYSSA MANDRELLE (RD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MANDRELLE
Last Name:CHAFE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 FORT ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2076
Mailing Address - Country:US
Mailing Address - Phone:402-493-2089
Mailing Address - Fax:
Practice Address - Street 1:10808 FORT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2076
Practice Address - Country:US
Practice Address - Phone:402-493-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002132133V00000X
NE1058133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered