Healthcare Provider Details

I. General information

NPI: 1831244490
Provider Name (Legal Business Name): LINDA BETH CORLISS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDA BETH SMITH

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/27/2023
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST SUITE E352
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

601 JOHN ST SUITE E352
KALAMAZOO MI
49007-5341
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-8986
  • Fax: 269-341-6236
Mailing address:
  • Phone: 269-341-8986
  • Fax: 269-341-6236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704172555
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: