Provider Demographics
NPI:1497575443
Name:DISOSO, ALYSSA (APRN, AGACNP)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:DISOSO
Suffix:
Gender:F
Credentials:APRN, AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 PINE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9679
Mailing Address - Country:US
Mailing Address - Phone:985-502-8556
Mailing Address - Fax:
Practice Address - Street 1:121 LAKEVIEW CIR STE A
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7521
Practice Address - Country:US
Practice Address - Phone:985-400-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201773363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner