Healthcare Provider Details

I. General information

NPI: 1487591699
Provider Name (Legal Business Name): ALYSSA LOUISE EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 E 3RD AVE
BAY SHORE NY
11706-2510
US

IV. Provider business mailing address

1640 E 3RD AVE
BAY SHORE NY
11706-2510
US

V. Phone/Fax

Practice location:
  • Phone: 631-894-7531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number347192-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: