Basic Information
| Provider Information | |||||||||
| NPI: | 1740234137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIDERMAN | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | PHOEBUS | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP-A | ||||||||
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| OtherLastName: | PHOEBUS | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210311002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436433000 | ||||||||
| FaxNumber: | 4436433001 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 UPPER CHESAPEAKE DR | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210144328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434633000 | ||||||||
| FaxNumber: | 4436433001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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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 | 363LA2200X | R157837 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.