Provider Demographics
NPI:1639757388
Name:PATTERSON, ALISA DANIELLE
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:DANIELLE
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:DANIELLE
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3710 W VERNER DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2990
Mailing Address - Country:US
Mailing Address - Phone:773-916-1292
Mailing Address - Fax:
Practice Address - Street 1:3710 W VERNER DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2990
Practice Address - Country:US
Practice Address - Phone:773-916-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02252019Medicaid