Provider Demographics
NPI:1508440736
Name:LECLAIR, KARISSA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:KARISSA
Middle Name:LYNN
Last Name:LECLAIR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1500 E. MEDICAL CENTER DRIVE, SPC 5312
Mailing Address - Street 2:TAUBMAN CENTER, 1ST FLOOR, ROOM 1903
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5312
Mailing Address - Country:US
Mailing Address - Phone:734-736-9178
Mailing Address - Fax:734-936-9625
Practice Address - Street 1:1500 E. MEDICAL CENTER DRIVE, SPC 5312
Practice Address - Street 2:TAUBMAN CENTER, 1ST FLOOR, ROOM 1903
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5312
Practice Address - Country:US
Practice Address - Phone:734-736-9178
Practice Address - Fax:734-936-9625
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351047781390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program