Healthcare Provider Details

I. General information

NPI: 1952544991
Provider Name (Legal Business Name): ALISSA NONGYAO WORSTELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S CREASY LN
LAFAYETTE IN
47905-4972
US

IV. Provider business mailing address

PO BOX 78838
DETROIT MI
48278-0838
US

V. Phone/Fax

Practice location:
  • Phone: 765-502-4000
  • Fax: 765-504-4687
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28182413C
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCERTIFICATE # 080969
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28182413A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: