Healthcare Provider Details

I. General information

NPI: 1093256257
Provider Name (Legal Business Name): MS. MARISA K CORONA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE STE 160
GRAND RAPIDS MI
49546-8313
US

IV. Provider business mailing address

601 BOND AVE NW UNIT 606
GRAND RAPIDS MI
49503-1493
US

V. Phone/Fax

Practice location:
  • Phone: 586-295-7040
  • Fax:
Mailing address:
  • Phone: 586-295-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47219
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: