MEDICARE: NICOLE CORLISS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WL0100X	Lactation Consultant (Registered Nurse)	L-301931	TX

General Provider Information

NPI Number	:	1518551308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE CORLISS

Provider Business Mailing Address
First Line	:	340 TREELINE PARK APT 1633
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1845
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 TREELINE PARK APT 1633
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1845
Country	:	US
Telephone Number	:	714-269-6557
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2021
Last Update Date	:	02/23/2021

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Directions to “ NICOLE CORLISS ” Practice Location

Language	Start Address	Practice Location

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