Provider Demographics
NPI:1790213932
Name:GRISSOM, ALYSSA (APN, AGCNS)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:APN, AGCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9436 S KOLMAR AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2694
Mailing Address - Country:US
Mailing Address - Phone:937-248-3166
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH ST.
Practice Address - Street 2:8TH FLOOR OUTPATIENT PAVILLION
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-684-2064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014163364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health