Provider Demographics
NPI:1912423799
Name:NICKERSON, ALISSA LAUREN (AUD)
Entity Type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:LAUREN
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:
Practice Address - Street 1:1920 E CAMBRIDGE AVE STE 201
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1462
Practice Address - Country:US
Practice Address - Phone:602-933-3277
Practice Address - Fax:602-933-4326
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA10810231H00000X
IL147-001637231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist