Basic Information
| Provider Information | |||||||||
| NPI: | 1467180208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | JEANETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOCAN | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | JEANETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 23222 WOODLAWN RDG | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782592262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103935185 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22906 US HIGHWAY 281 N STE 108 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782587635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107745018 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2022 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1086196 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 44225 | 01 | TX | TEXAS STATE BOARD OF NURSING | OTHER |