Healthcare Provider Details

I. General information

NPI: 1760107767
Provider Name (Legal Business Name): ALAYSA THYGERSEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 PALM AVE
IMPERIAL BEACH CA
91932-1503
US

IV. Provider business mailing address

949 PALM AVE
IMPERIAL BEACH CA
91932-1503
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-3733
  • Fax:
Mailing address:
  • Phone: 619-429-3733
  • Fax: 619-429-3826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: