Provider Demographics
NPI:1114262730
Name:WESSA, KARRISA JEAN (LMP)
Entity Type:Individual
Prefix:
First Name:KARRISA
Middle Name:JEAN
Last Name:WESSA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17817 NE 201ST ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-3634
Mailing Address - Country:US
Mailing Address - Phone:360-450-9376
Mailing Address - Fax:
Practice Address - Street 1:119 S PARKWAY AVE
Practice Address - Street 2:STE 101
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-5499
Practice Address - Country:US
Practice Address - Phone:360-666-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60060120225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist