Healthcare Provider Details

I. General information

NPI: 1730920026
Provider Name (Legal Business Name): ALYSSA KJERULF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 CHARTER DR STE 130
COLUMBIA MD
21044-3258
US

IV. Provider business mailing address

10200 GRAND CENTRAL AVE STE 220
OWINGS MILLS MD
21117-4366
US

V. Phone/Fax

Practice location:
  • Phone: 410-772-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009442
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: