Provider Demographics
NPI:1902493299
Name:LOOSE, KARISSA (LPN)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:LOOSE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14222 TAUS RD
Mailing Address - Street 2:
Mailing Address - City:REEDSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54230-8162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14222 TAUS RD
Practice Address - Street 2:
Practice Address - City:REEDSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54230-8162
Practice Address - Country:US
Practice Address - Phone:920-973-4027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI325186164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse