Healthcare Provider Details

I. General information

NPI: 1902493299
Provider Name (Legal Business Name): KARISSA LOOSE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14222 TAUS RD
REEDSVILLE WI
54230-8162
US

IV. Provider business mailing address

14222 TAUS RD
REEDSVILLE WI
54230-8162
US

V. Phone/Fax

Practice location:
  • Phone: 920-973-4027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number325186
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: