Provider Demographics
NPI:1073945580
Name:KOERNER, KARISSA LYNN
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:LYNN
Last Name:KOERNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 SPUR DR S
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3908
Mailing Address - Country:US
Mailing Address - Phone:631-666-5762
Mailing Address - Fax:
Practice Address - Street 1:179 SPUR DR S
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3908
Practice Address - Country:US
Practice Address - Phone:631-666-5762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY695120121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist