Basic Information
| Provider Information | |||||||||
| NPI: | 1245708130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TYSON | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | NANCY-ANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306556748 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Practice Location | |||||||||
| Address1: | 396 REMINGTON BLVD STE 330 | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307544317 | ||||||||
| FaxNumber: | 6307544317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2018 | ||||||||
| LastUpdateDate: | 07/03/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 041376699 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.