Healthcare Provider Details

I. General information

NPI: 1124988191
Provider Name (Legal Business Name): ALYSSA JEAN HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E BROADWAY
COLUMBIA MO
65201-4979
US

IV. Provider business mailing address

1408 23RD ST S
FARGO ND
58103-3709
US

V. Phone/Fax

Practice location:
  • Phone: 573-442-2211
  • Fax:
Mailing address:
  • Phone: 701-318-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: