Provider Demographics
NPI:1801417779
Name:SMALL, ALYSSA MAE (NP)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MAE
Last Name:SMALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:995 WILLAGILLESPIE RD STE 300
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2153
Practice Address - Country:US
Practice Address - Phone:541-228-9700
Practice Address - Fax:541-228-9700
Is Sole Proprietor?:No
Enumeration Date:2020-05-02
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10009473363LF0000X
IN71010933A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily