Healthcare Provider Details

I. General information

NPI: 1114384922
Provider Name (Legal Business Name): ALYSSA VANPATTEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W CLARKE ST APT 12
MANCHESTER NH
03104-2449
US

IV. Provider business mailing address

180 W CLARKE ST APT 12
MANCHESTER NH
03104-2449
US

V. Phone/Fax

Practice location:
  • Phone: 518-956-1803
  • Fax: 603-222-4091
Mailing address:
  • Phone: 518-956-1803
  • Fax: 603-222-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number2000006325
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: