Provider Demographics
NPI:1215276993
Name:PAMENTER, ALYSSA MARIE (APRN)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:PAMENTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:MARIE
Other - Last Name:PAMENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2338 CITADEL WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6184
Mailing Address - Country:US
Mailing Address - Phone:321-292-9063
Mailing Address - Fax:
Practice Address - Street 1:2338 CITADEL WAY STE 105
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-6184
Practice Address - Country:US
Practice Address - Phone:321-292-9063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2021-10-20
Deactivation Date:2021-05-25
Deactivation Code:
Reactivation Date:2021-08-20
Provider Licenses
StateLicense IDTaxonomies
WI181289163W00000X
FL1215276993363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse