Healthcare Provider Details

I. General information

NPI: 1104451632
Provider Name (Legal Business Name): ALYSSA CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 04/02/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WHITE STREET
CAMBRIDGE MA
02140
US

IV. Provider business mailing address

36 WHITE STREET
CAMBRIDGE MA
02140
US

V. Phone/Fax

Practice location:
  • Phone: 617-876-5519
  • Fax:
Mailing address:
  • Phone: 617-876-5519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2293870
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: