Provider Demographics
NPI:1063003648
Name:MAMMEN, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:MAMMEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-4505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:508-674-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2329584163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine