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General NPI Number Information
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NPI Number | 1437740503
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Entity Type | Individual
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Provider Name | CORISSA M LEASE
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Gender | Female
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Dates
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Enumeration Date | 02/01/2021
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Last Update Date | 02/01/2021
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Provider Practice Location Address
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Address Line | 1218 STATE ST
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City | BLACK EARTH
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State | WI
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Zip | 53515
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Country | US
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Telephone | 608-767-2572
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Fax |
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Provider Business Mailing Address
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Address Line | 308 S HARRISON ST
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City | BELLEVILLE
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State | WI
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Zip | 53508-9302
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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