Provider Demographics
NPI:1043455702
Name:CORKER, MICHELE MARIE
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:MARIE
Last Name:CORKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22479 HUNTINGTON CT
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1425
Mailing Address - Country:US
Mailing Address - Phone:734-692-8056
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R
Practice Address - Street 2:JOHN D. DINGELL VA MEDICAL CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-576-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704226006364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult