Provider Demographics
NPI:1023607652
Name:REISER, KARISSA SUSAN
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:SUSAN
Last Name:REISER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19508 LACI ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-4266
Mailing Address - Country:US
Mailing Address - Phone:402-340-1631
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH AVE STE 4199
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1850
Practice Address - Country:US
Practice Address - Phone:800-451-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE113334363L00000X
NE113336363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner