Healthcare Provider Details

I. General information

NPI: 1265199731
Provider Name (Legal Business Name): JOSHUA DAVID CORREIA BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 KILLINGTON AVE
RUTLAND VT
05701-4227
US

IV. Provider business mailing address

87 KILLINGTON AVE
RUTLAND VT
05701-4227
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-0688
  • Fax:
Mailing address:
  • Phone: 505-321-0688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number026.0136889
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: