Healthcare Provider Details

I. General information

NPI: 1114766805
Provider Name (Legal Business Name): KORY MARSLAND CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 TIOGA ST UNIT 6834
ITHACA NY
14851-8068
US

IV. Provider business mailing address

1115 1ST ST N
STILLWATER MN
55082-4037
US

V. Phone/Fax

Practice location:
  • Phone: 608-400-0141
  • Fax: 608-561-8745
Mailing address:
  • Phone: 608-400-0141
  • Fax: 608-561-8745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: TISHA PALMER
Title or Position: PRACTICE MANAGER
Credential: RN
Phone: 608-400-0141