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: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 25TH ST S
FARGO ND
58103-6104
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-6130
  • Fax: 701-280-4492
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-328-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC1213
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: