Provider Demographics
NPI:1417535717
Name:HAGEN, KARISSA M (NP)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:M
Last Name:HAGEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KARISSA
Other - Middle Name:M
Other - Last Name:NOFFKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 MEDICAL PARK DRIVE SUITE 320
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6771
Practice Address - Fax:803-434-3955
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24338363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care