Provider Demographics
NPI:1700291515
Name:VERMEULEN, ALYSSA M (DO)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:M
Last Name:VERMEULEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2345
Mailing Address - Country:US
Mailing Address - Phone:231-935-6370
Mailing Address - Fax:231-935-6451
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-6370
Practice Address - Fax:231-935-6451
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021415208000000X
IL036.1425742080P0202X
MI51010255742080P0202X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology