Healthcare Provider Details

I. General information

NPI: 1386469336
Provider Name (Legal Business Name): ALYSSA VAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MALTON RD STE 6
NEGAUNEE MI
49866-2002
US

IV. Provider business mailing address

100 MALTON RD
NEGAUNEE MI
49866-2001
US

V. Phone/Fax

Practice location:
  • Phone: 906-485-2347
  • Fax: 906-486-1150
Mailing address:
  • Phone: 906-228-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: