Provider Demographics
NPI:1346708435
Name:POPPEN, KARISSA ANN (PT)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:ANN
Last Name:POPPEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 JASPER DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1127
Mailing Address - Country:US
Mailing Address - Phone:309-229-4754
Mailing Address - Fax:
Practice Address - Street 1:2500 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9774
Practice Address - Country:US
Practice Address - Phone:815-842-2828
Practice Address - Fax:815-842-4912
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0239472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic