Provider Demographics
NPI:1356726046
Name:ROE, ALISSA S (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:S
Last Name:ROE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:S
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:1460 COLBURN DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-7053
Mailing Address - Country:US
Mailing Address - Phone:740-705-2003
Mailing Address - Fax:
Practice Address - Street 1:945 BETHESDA DR STE 130
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1880
Practice Address - Country:US
Practice Address - Phone:740-454-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.17765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0141509Medicaid