Healthcare Provider Details

I. General information

NPI: 1316352669
Provider Name (Legal Business Name): CORRIE TIVIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1929 N 11TH ST APT 5
BISMARCK ND
58501-1916
US

IV. Provider business mailing address

1929 N 11TH ST APT 5
BISMARCK ND
58501-1916
US

V. Phone/Fax

Practice location:
  • Phone: 701-206-0414
  • Fax:
Mailing address:
  • Phone: 701-206-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberR31795
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: