Provider Demographics
NPI:1033540638
Name:WHITTAKER, ALISSA (FNP)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2219 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3212
Practice Address - Country:US
Practice Address - Phone:574-371-9550
Practice Address - Fax:574-376-4793
Is Sole Proprietor?:No
Enumeration Date:2013-12-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28186867A363LF0000X
IN71004885A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151020023OtherMEDICARE PTAN
IN201222850Medicaid