Healthcare Provider Details

I. General information

NPI: 1891188934
Provider Name (Legal Business Name): HAYLEY ROXANNE CORSO AT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 NORTHVIEW PL
HURON OH
44839-1135
US

IV. Provider business mailing address

39 NORTHVIEW PL
HURON OH
44839-1135
US

V. Phone/Fax

Practice location:
  • Phone: 419-602-7172
  • Fax:
Mailing address:
  • Phone: 419-602-7172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number004488
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: