Healthcare Provider Details

I. General information

NPI: 1912423799
Provider Name (Legal Business Name): ALISSA LAUREN NICKERSON AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E CAMBRIDGE AVE STE 201
PHOENIX AZ
85006-1462
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-3277
  • Fax: 602-933-4326
Mailing address:
  • Phone: 602-933-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberDA10810
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147-001637
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: