=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003301995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA HENRY PROFFITT PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 LAKE RAY RD
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32640-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-284-1402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 LAKE RAY RD
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32640-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-284-1402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------