1710426879 NPI number — MRS. ALYSSA DANIELLE GUNAWAN FNP-C

Table of content: MRS. ALYSSA DANIELLE GUNAWAN FNP-C (NPI 1710426879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710426879 NPI number — MRS. ALYSSA DANIELLE GUNAWAN FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNAWAN
Provider First Name:
ALYSSA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
MRS.
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:
SALAS
Provider Other First Name:
ALYSSA
Provider Other Middle Name:
DANIELLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710426879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3413 ALEXANDER CIR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30326-1268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-694-1260
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3369 BUFORD HWY NE
Provider Second Line Business Practice Location Address:
SUITE NUMBER 810
Provider Business Practice Location Address City Name:
BROOKHAVEN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30329-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-321-4692
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2017

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:  RN264580 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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