Provider Demographics
NPI:1295482966
Name:COCKERHAM, KARISSA MALLEAH (HIS)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:MALLEAH
Last Name:COCKERHAM
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-3326
Mailing Address - Country:US
Mailing Address - Phone:615-942-0520
Mailing Address - Fax:
Practice Address - Street 1:4825 TROUSDALE DR STE 209
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37220-1307
Practice Address - Country:US
Practice Address - Phone:615-942-0520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN995237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty