Provider Demographics
NPI:1013383934
Name:CORLISS, KATRINA (MT)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:CORLISS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 E STAGE RD
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-9718
Mailing Address - Country:US
Mailing Address - Phone:307-330-3012
Mailing Address - Fax:
Practice Address - Street 1:29 BLACK COAL RD
Practice Address - Street 2:LABORATORY
Practice Address - City:FT WASHACKI
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-335-5973
Practice Address - Fax:307-332-7514
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAAB 2050187246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist