Healthcare Provider Details

I. General information

NPI: 1508545591
Provider Name (Legal Business Name): ALYSSA ANN VACTOR APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA JONES

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 FAIRINGTON DR
SIDNEY OH
45365-8130
US

IV. Provider business mailing address

1535 GRIMES AVE
URBANA OH
43078-1013
US

V. Phone/Fax

Practice location:
  • Phone: 937-497-5561
  • Fax:
Mailing address:
  • Phone: 937-507-1118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0034380
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: