Healthcare Provider Details

I. General information

NPI: 1518309012
Provider Name (Legal Business Name): ALISSA J KYSAR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37712 NE KELLY RD
YACOLT WA
98675-4725
US

IV. Provider business mailing address

37712 NE KELLY RD
YACOLT WA
98675-4725
US

V. Phone/Fax

Practice location:
  • Phone: 360-247-6767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00129974
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: