Healthcare Provider Details

I. General information

NPI: 1841290632
Provider Name (Legal Business Name): ALYSSA K DOSMANN MNT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 PARK PL
MISHAWAKA IN
46545-3519
US

IV. Provider business mailing address

221 RED COACH DR SUITE D
MISHAWAKA IN
46545-8323
US

V. Phone/Fax

Practice location:
  • Phone: 574-273-6787
  • Fax: 574-968-0882
Mailing address:
  • Phone: 574-273-6787
  • Fax: 574-968-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number37001544A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: