Provider Demographics
NPI:1124988191
Name:HENRY, ALYSSA JEAN
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JEAN
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3709
Mailing Address - Country:US
Mailing Address - Phone:701-318-8866
Mailing Address - Fax:
Practice Address - Street 1:1200 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4979
Practice Address - Country:US
Practice Address - Phone:573-442-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant