=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740922640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALYSSA JOHNSTON REGISTERED NURSING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2022
-----------------------------------------------------
Last Update Date | 04/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1814 CIRBY WAY APT B
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-5564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-876-9602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1814 CIRBY WAY APT B
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-5564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-876-9602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ATTENDING PHYSICIAN
-----------------------------------------------------
Name | JACOB SUNG KEUM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-876-9602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------