Basic Information
| Provider Information | |||||||||
| NPI: | 1396287769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONERGAN | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 WESTGATE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516359173 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 WESTGATE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516359173 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2016 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12910-24 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 9046 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 12910-24 | 01 | MN | STATE LICENSE | OTHER |