Healthcare Provider Details

I. General information

NPI: 1366286270
Provider Name (Legal Business Name): ALYSSA LOURDES VALLEE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 SANDERSON RD STE 201
SMITHFIELD RI
02917-2603
US

IV. Provider business mailing address

10 DAVOL SQ STE 400
PROVIDENCE RI
02903-4752
US

V. Phone/Fax

Practice location:
  • Phone: 401-949-0300
  • Fax:
Mailing address:
  • Phone: 401-421-4000
  • Fax: 401-272-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01708
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: