Provider Demographics
NPI:1396352142
Name:THUESON, KARISSA (NNP)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:THUESON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N 3811 E
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5186
Mailing Address - Country:US
Mailing Address - Phone:208-497-8114
Mailing Address - Fax:
Practice Address - Street 1:450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2048
Practice Address - Country:US
Practice Address - Phone:208-359-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID65959363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal