Provider Demographics
NPI:1245706605
Name:VIDAL, ALYSSA (FNP-C)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 PARK SIERRA DR STE 203
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3071
Mailing Address - Country:US
Mailing Address - Phone:951-687-3400
Mailing Address - Fax:951-687-7630
Practice Address - Street 1:3989 W STETSON AVE STE 202
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9697
Practice Address - Country:US
Practice Address - Phone:951-652-3558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95148321163WD1100X, 163WR0400X
CA95022142363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation