Healthcare Provider Details

I. General information

NPI: 1700373644
Provider Name (Legal Business Name): BALEY ALYSSA MIKITA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W OAK ST
BOSCOBEL WI
53805-1519
US

IV. Provider business mailing address

841 RIVERFRONT DR
SHEBOYGAN WI
53081-4656
US

V. Phone/Fax

Practice location:
  • Phone: 608-375-2411
  • Fax:
Mailing address:
  • Phone: 920-234-6852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5395-12
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: