Provider Demographics
NPI:1396190328
Name:SOUTHWAY, ALISSA (FNP-C)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:SOUTHWAY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45726 PENTWATER DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4237
Mailing Address - Country:US
Mailing Address - Phone:586-382-5711
Mailing Address - Fax:
Practice Address - Street 1:46600 ROMEO PLANK RD
Practice Address - Street 2:SUITE #4
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5741
Practice Address - Country:US
Practice Address - Phone:586-228-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704284597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily