Provider Demographics
NPI:1386284685
Name:BORBA, ALYSSE LYNETTE (CRMII, PSS, CRGM)
Entity type:Individual
Prefix:
First Name:ALYSSE
Middle Name:LYNETTE
Last Name:BORBA
Suffix:
Gender:F
Credentials:CRMII, PSS, CRGM
Other - Prefix:
Other - First Name:ALYSSE
Other - Middle Name:LYNETTE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRMII, PSS, CRGM
Mailing Address - Street 1:1111 CRATER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6241
Mailing Address - Country:US
Mailing Address - Phone:971-219-3314
Mailing Address - Fax:
Practice Address - Street 1:1111 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6241
Practice Address - Country:US
Practice Address - Phone:971-219-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-CRM-II-0138175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist