Provider Demographics
NPI:1770826208
Name:ROCKETT, ALISA JEANETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:JEANETTE
Last Name:ROCKETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:ALISA
Other - Middle Name:JEANETTE
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:440 CENTRAL AVE
Mailing Address - Street 2:APT 2B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-5069
Mailing Address - Country:US
Mailing Address - Phone:347-404-6769
Mailing Address - Fax:
Practice Address - Street 1:440 CENTRAL AVE
Practice Address - Street 2:APT 2B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-5069
Practice Address - Country:US
Practice Address - Phone:347-404-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313870164W00000X
NJ26NP06874400164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXJ83660TMedicaid