Provider Demographics
NPI:1417109158
Name:MCDIVITT, ALISSA D (FNP-C)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:D
Last Name:MCDIVITT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:D
Other - Last Name:MCDIVITT-COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:10255 COMMERCE DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032
Mailing Address - Country:US
Mailing Address - Phone:317-449-3958
Mailing Address - Fax:866-400-7088
Practice Address - Street 1:10255 COMMERCE DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-449-3958
Practice Address - Fax:866-400-7088
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002973A363LF0000X
OHCOA.10035-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000709399OtherANTHEM
IN200997530Medicaid
IN940940C8Medicare PIN