Provider Demographics
NPI:1114356714
Name:BLANK, CARISSA FAWN (LPN)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:FAWN
Last Name:BLANK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:FAWN
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25110 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:VENETA
Mailing Address - State:OR
Mailing Address - Zip Code:97487-9756
Mailing Address - Country:US
Mailing Address - Phone:541-505-0498
Mailing Address - Fax:
Practice Address - Street 1:151 W 7TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-1100
Practice Address - Country:US
Practice Address - Phone:541-682-8779
Practice Address - Fax:541-682-9924
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201393726LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse