Healthcare Provider Details

I. General information

NPI: 1699492421
Provider Name (Legal Business Name): ALYSSA JANE SACKETT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 11TH ST
HAWARDEN IA
51023-1903
US

IV. Provider business mailing address

1110 LUCAS AVE
PIERSON IA
51048-8071
US

V. Phone/Fax

Practice location:
  • Phone: 712-551-3100
  • Fax:
Mailing address:
  • Phone: 515-450-8335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA171569
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: