Healthcare Provider Details

I. General information

NPI: 1114508629
Provider Name (Legal Business Name): ALYSSA ALICEA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 HUNTINGDON PIKE STE 100
ROCKLEDGE PA
19046-4351
US

IV. Provider business mailing address

3500 N BROAD ST RM 1A
PHILADELPHIA PA
19140-4106
US

V. Phone/Fax

Practice location:
  • Phone: 215-663-8880
  • Fax:
Mailing address:
  • Phone: 215-926-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS023933
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: