1417109158 NPI number — ALISSA D MCDIVITT FNP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417109158 NPI number — ALISSA D MCDIVITT FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDIVITT
Provider First Name:
ALISSA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCDIVITT-COX
Provider Other First Name:
ALISSA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417109158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10255 COMMERCE DRIVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-449-3958
Provider Business Mailing Address Fax Number:
866-400-7088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10255 COMMERCE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-449-3958
Provider Business Practice Location Address Fax Number:
866-400-7088
Provider Enumeration Date:
10/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  71002973A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: COA.10035-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000709399 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200997530 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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