Healthcare Provider Details

I. General information

NPI: 1740922640
Provider Name (Legal Business Name): ALYSSA JOHNSTON REGISTERED NURSING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 CIRBY WAY APT B
ROSEVILLE CA
95661-5564
US

IV. Provider business mailing address

1814 CIRBY WAY APT B
ROSEVILLE CA
95661-5564
US

V. Phone/Fax

Practice location:
  • Phone: 770-876-9602
  • Fax:
Mailing address:
  • Phone: 770-876-9602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JACOB SUNG KEUM
Title or Position: ATTENDING PHYSICIAN
Credential: MD
Phone: 770-876-9602