Provider Demographics
NPI:1710598669
Name:NOOMEN, ALYSSA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:NOOMEN
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 1:1245 CENTERVILLE LN APT B
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89460-9726
Mailing Address - Country:US
Mailing Address - Phone:859-707-9430
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE STE B200
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-4644
Practice Address - Country:US
Practice Address - Phone:859-257-3533
Practice Address - Fax:859-257-6024
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV823076208800000X
KY3017510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV820376Medicaid