Provider Demographics
NPI:1932871258
Name:PHOUMMALAYVANE, ALYSSAH (FNP)
Entity Type:Individual
Prefix:MISS
First Name:ALYSSAH
Middle Name:
Last Name:PHOUMMALAYVANE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 PLEASANT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1909
Mailing Address - Country:US
Mailing Address - Phone:774-402-4774
Mailing Address - Fax:
Practice Address - Street 1:326 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1914
Practice Address - Country:US
Practice Address - Phone:978-878-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2310990363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily