Provider Demographics
NPI:1205533155
Name:CARSON, CLARISSA EVANELL (PMHNP)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:EVANELL
Last Name:CARSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7667
Mailing Address - Country:US
Mailing Address - Phone:541-773-3863
Mailing Address - Fax:541-842-7640
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7136
Practice Address - Country:US
Practice Address - Phone:541-842-7705
Practice Address - Fax:541-842-7640
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10004386363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health