Healthcare Provider Details

I. General information

NPI: 1891281432
Provider Name (Legal Business Name): ALYSSA VIRGINIA JOHNSTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALYSSA VIRGINIA MAKOWSKI

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date: 11/21/2019
Reactivation Date: 11/27/2019

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 TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number95013336
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013336
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: