Healthcare Provider Details

I. General information

NPI: 1831658020
Provider Name (Legal Business Name): ALISSA ICE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5246 BRITTANY DR
BATON ROUGE LA
70808-9136
US

IV. Provider business mailing address

5246 BRITTANY DR
BATON ROUGE LA
70808-9136
US

V. Phone/Fax

Practice location:
  • Phone: 225-757-4080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1831658020
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number329986
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number1831658020
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: