Provider Demographics
NPI:1538642863
Name:HENNEBOEHLE, ALYSSA VANDERSLICE (NP)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:VANDERSLICE
Last Name:HENNEBOEHLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:LAINE
Other - Last Name:VANDERSLICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 740019
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0019
Mailing Address - Country:US
Mailing Address - Phone:773-644-3941
Mailing Address - Fax:
Practice Address - Street 1:3451 UNION BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-1142
Practice Address - Country:US
Practice Address - Phone:314-888-0970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024019220363L00000X
COAPN.0994741-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner