Healthcare Provider Details

I. General information

NPI: 1629972286
Provider Name (Legal Business Name): ALYSSA LAURIANNA VINCENZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1237 TALBRIDGE WAY
SAINT CHARLES MO
63303-4847
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-3291
  • Fax:
Mailing address:
  • Phone: 314-550-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2026044745
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: