Healthcare Provider Details

I. General information

NPI: 1649182866
Provider Name (Legal Business Name): ALISSA ROSE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 PROSPECT AVE
HACKENSACK NJ
07601-2519
US

IV. Provider business mailing address

34 MAPLE PL
NUTLEY NJ
07110-1727
US

V. Phone/Fax

Practice location:
  • Phone: 551-309-3555
  • Fax:
Mailing address:
  • Phone: 862-333-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15654500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: