Healthcare Provider Details

I. General information

NPI: 1801750260
Provider Name (Legal Business Name): ALISSA HENNEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 MAIN ST.
BUIES CREEK NC
27506
US

IV. Provider business mailing address

3600 ROCK CREEK DR
RALEIGH NC
27609-7127
US

V. Phone/Fax

Practice location:
  • Phone: 312-953-9922
  • Fax:
Mailing address:
  • Phone: 312-953-9922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: