Provider Demographics
NPI:1780929281
Name:JOHNSON, ALYSSA HITCH (LAC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:HITCH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:RICHARDS
Other - Last Name:HITCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:971 MOUNTAIN WILLOW LANE
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:828-699-4832
Mailing Address - Fax:
Practice Address - Street 1:971 MOUNTAIN WILLOW LN
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4610
Practice Address - Country:US
Practice Address - Phone:828-699-4832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8453211-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8453211-1201OtherUTAH ACUPUNCTURE LICENSE NUMBER