Basic Information
| Provider Information | |||||||||
| NPI: | 1609002179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 275 E 200 S STE 200 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841112002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003661884 | ||||||||
| FaxNumber: | 8669908119 | ||||||||
| Practice Location | |||||||||
| Address1: | ADVENTIST HEALTHCARE WHITE OAK MEDICAL CENTER | ||||||||
| Address2: | 11890 HEALING WAY | ||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME104742 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 28259 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 52016 | CT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036141714 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | Q3011 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 253856 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | D87570 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.