Provider Demographics
NPI:1154900843
Name:DEFOREST SJAHRIAL, ALISON LYN
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:LYN
Last Name:DEFOREST SJAHRIAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:LYN
Other - Last Name:DEFOREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3980 9TH AVE UNIT 208
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3247
Mailing Address - Country:US
Mailing Address - Phone:510-676-0192
Mailing Address - Fax:
Practice Address - Street 1:3980 9TH AVE UNIT 208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3247
Practice Address - Country:US
Practice Address - Phone:510-676-0192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program