Healthcare Provider Details

I. General information

NPI: 1417543273
Provider Name (Legal Business Name): ALYSSA J CONRAD NUTRITIONIST PN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 FM 1463 RD
KATY TX
77494-5478
US

IV. Provider business mailing address

1432 FM 1463 RD
KATY TX
77494-5478
US

V. Phone/Fax

Practice location:
  • Phone: 281-395-2225
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: