Healthcare Provider Details

I. General information

NPI: 1356988463
Provider Name (Legal Business Name): ALISSA LYNN CLAWSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

10315 DAWSONS CREEK BLVD
FORT WAYNE IN
46825-1912
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7001
  • Fax:
Mailing address:
  • Phone: 260-442-3502
  • Fax: 260-442-3598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number128763
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: