Provider Demographics
NPI:1952544991
Name:WORSTELL, ALISSA NONGYAO (CRNA)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:NONGYAO
Last Name:WORSTELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78838
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-0838
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:765-502-4000
Practice Address - Fax:765-504-4687
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28182413C367500000X
INCERTIFICATE # 080969367500000X
IN28182413A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000610409OtherANTHEM PROVIDER NUMBER
IN200948140Medicaid
IN815500AA2Medicare PIN
IN000000610409OtherANTHEM PROVIDER NUMBER