Healthcare Provider Details

I. General information

NPI: 1619642634
Provider Name (Legal Business Name): ALYSSA ANN MASKELL AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 S SAN VICENTE BLVD
LOS ANGELES CA
90048-3311
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-1160
  • Fax: 310-423-4646
Mailing address:
  • Phone: 310-423-1160
  • Fax: 310-423-4646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95018261
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95018261
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number95139717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: