=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740522036
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA A. JASTRZEBSKI FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2013
-----------------------------------------------------
Last Update Date | 10/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308C MOCKSVILLE HWY
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28625-8267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-873-4484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18427 THE COMMONS BLVD
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-7072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-622-0692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5006115
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------