Provider Demographics
NPI:1619775889
Name:DUCKWORTH, ALYSSA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:DUCKWORTH
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 1:780 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2950
Mailing Address - Country:US
Mailing Address - Phone:614-795-7591
Mailing Address - Fax:
Practice Address - Street 1:780 STEWART AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-2950
Practice Address - Country:US
Practice Address - Phone:614-795-7591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 374J00000X, 374U00000X
OH184292164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No172V00000XOther Service ProvidersCommunity Health Worker
No374J00000XNursing Service Related ProvidersDoula
No374U00000XNursing Service Related ProvidersHome Health Aide