Provider Demographics
NPI:1427650456
Name:FUNK, ALYSSA J
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:J
Last Name:FUNK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 PROVINCETOWN RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1909 PROVINCETOWN RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3439
Practice Address - Country:US
Practice Address - Phone:937-245-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health