Healthcare Provider Details

I. General information

NPI: 1972131878
Provider Name (Legal Business Name): ALYSSA WALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 10/18/2022
Certification Date: 09/22/2022
Deactivation Date: 07/13/2020
Reactivation Date: 08/25/2021

III. Provider practice location address

4075 OLD WESTERN ROW RD
MASON OH
45040-3104
US

IV. Provider business mailing address

4075 OLD WESTERN ROW RD
MASON OH
45040-3104
US

V. Phone/Fax

Practice location:
  • Phone: 513-536-4673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number219471
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number30113
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0031874
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number511767
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: