Healthcare Provider Details

I. General information

NPI: 1790402493
Provider Name (Legal Business Name): KARISSA L KIRKWOOD CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CROSSLAKE DR
EVANSVILLE IN
47715-8198
US

IV. Provider business mailing address

225 CROSSLAKE DR
EVANSVILLE IN
47715-8198
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-1558
  • Fax:
Mailing address:
  • Phone: 812-477-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: