Healthcare Provider Details

I. General information

NPI: 1265117857
Provider Name (Legal Business Name): ALISA ANAIS MCKNIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 MCHENRY AVE
MODESTO CA
95350-4528
US

IV. Provider business mailing address

1298 HEARTLAND DR
MANTECA CA
95337-8069
US

V. Phone/Fax

Practice location:
  • Phone: 209-702-0139
  • Fax: 209-758-0825
Mailing address:
  • Phone: 209-429-1273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95025867
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number279045
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: