Provider Demographics
NPI:1679028708
Name:ELY, ALYSA RAE (RN)
Entity Type:Individual
Prefix:
First Name:ALYSA
Middle Name:RAE
Last Name:ELY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 SE CHEDESTER RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OR
Mailing Address - Zip Code:97391-2411
Mailing Address - Country:US
Mailing Address - Phone:541-265-0581
Mailing Address - Fax:541-574-6252
Practice Address - Street 1:36 SW NYE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3821
Practice Address - Country:US
Practice Address - Phone:541-265-0581
Practice Address - Fax:541-574-6252
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201505814RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse