Basic Information
Provider Information | |||||||||
NPI: | 1619642634 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MASKELL | ||||||||
FirstName: | ALYSSA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AGPCNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4140 W 190TH ST | ||||||||
Address2: |   | ||||||||
City: | TORRANCE | ||||||||
State: | CA | ||||||||
PostalCode: | 905045513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104231160 | ||||||||
FaxNumber: | 3104234646 | ||||||||
Practice Location | |||||||||
Address1: | 127 S SAN VICENTE BLVD | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900483311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104231160 | ||||||||
FaxNumber: | 3104234646 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2021 | ||||||||
LastUpdateDate: | 07/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | 95139717 | CA | N |   | Nursing Service Providers | Registered Nurse | Medical-Surgical | 363L00000X | 95018261 | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LG0600X | 95018261 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.