Provider Demographics
NPI:1104490796
Name:VASSALLO, ELISSE (FNP-BC)
Entity type:Individual
Prefix:
First Name:ELISSE
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 VIA LOS MIRADORES
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-6760
Mailing Address - Country:US
Mailing Address - Phone:908-892-0781
Mailing Address - Fax:
Practice Address - Street 1:4676 ADMIRALTY WAY STE 301
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6601
Practice Address - Country:US
Practice Address - Phone:310-673-3945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017219363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily