Provider Demographics
NPI:1144797267
Name:RALLS, CORRIE L
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:L
Last Name:RALLS
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 1:1 ANGUS LN
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-3369
Mailing Address - Country:US
Mailing Address - Phone:618-833-3535
Mailing Address - Fax:
Practice Address - Street 1:1 ANGUS LN
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-3369
Practice Address - Country:US
Practice Address - Phone:618-697-1802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043091119164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid