Provider Demographics
NPI:1063899292
Name:IERVESE, ALISSA
Entity type:Individual
Prefix:MISS
First Name:ALISSA
Middle Name:
Last Name:IERVESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HIDDEN PHEASANT PATH
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2163
Mailing Address - Country:US
Mailing Address - Phone:631-316-9062
Mailing Address - Fax:
Practice Address - Street 1:9 HIDDEN PHEASANT PATH
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2163
Practice Address - Country:US
Practice Address - Phone:631-316-9062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315669-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse