Provider Demographics
NPI:1790208346
Name:LJUNGQUIST, ALYSSA (AGNP)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:LJUNGQUIST
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MESEROLE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-7804
Mailing Address - Country:US
Mailing Address - Phone:405-408-0522
Mailing Address - Fax:
Practice Address - Street 1:110 E 59TH ST STE 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1304
Practice Address - Country:US
Practice Address - Phone:212-434-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308095363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health