Healthcare Provider Details

I. General information

NPI: 1548991342
Provider Name (Legal Business Name): ALYSSA HAWK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA FOWLER

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7565 E US HIGHWAY 66
EL RENO OK
73036-9120
US

IV. Provider business mailing address

9901 SUNDANCE RIDGE RD
YUKON OK
73099-9264
US

V. Phone/Fax

Practice location:
  • Phone: 405-262-6555
  • Fax:
Mailing address:
  • Phone: 724-984-0639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: