Healthcare Provider Details

I. General information

NPI: 1316858665
Provider Name (Legal Business Name): ALYSSA CHRISTINE ELLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 18667
ERLANGER KY
41018-0667
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2250
  • Fax:
Mailing address:
  • Phone: 859-572-3617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: