Healthcare Provider Details

I. General information

NPI: 1013383934
Provider Name (Legal Business Name): KATRINA CORLISS MT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BLACK COAL RD LABORATORY
FT WASHACKI WY
82514
US

IV. Provider business mailing address

3223 E STAGE RD
IONIA MI
48846-9718
US

V. Phone/Fax

Practice location:
  • Phone: 307-335-5973
  • Fax: 307-332-7514
Mailing address:
  • Phone: 307-330-3012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberAAB 2050187
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: