Healthcare Provider Details

I. General information

NPI: 1912484908
Provider Name (Legal Business Name): ALYSSA KNAACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

42489 WILLSHARON ST
STERLING HEIGHTS MI
48314-3077
US

V. Phone/Fax

Practice location:
  • Phone: 248-321-8967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704299654
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704299654
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: