Healthcare Provider Details

I. General information

NPI: 1124367602
Provider Name (Legal Business Name): MARY SUSAN CORLISS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 PLEASANT ST
CONCORD NH
03301-2548
US

IV. Provider business mailing address

246 PLEASANT ST
CONCORD NH
03301-2548
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-6070
  • Fax: 603-224-6094
Mailing address:
  • Phone: 603-224-6070
  • Fax: 603-224-6094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number024092-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: