=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114766805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KORY MARSLAND CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2024
-----------------------------------------------------
Last Update Date | 05/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213 TIOGA ST UNIT 6834
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14851-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-400-0141
-----------------------------------------------------
Fax | 608-561-8745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1115 1ST ST N
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55082-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-400-0141
-----------------------------------------------------
Fax | 608-561-8745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | TISHA PALMER
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 608-400-0141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------