Healthcare Provider Details

I. General information

NPI: 1578024527
Provider Name (Legal Business Name): ALYSSA J PROVAGNA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4430 MISSOURI AVE
FORT LEONARD WOOD MO
65473-9098
US

IV. Provider business mailing address

4234 ILLINOIS AVE
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-1770
  • Fax:
Mailing address:
  • Phone: 573-596-1770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101270674
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number010127064
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: