Provider Demographics
NPI:1154450278
Name:CORCORAN, NICHOLLE DIANE (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLLE
Middle Name:DIANE
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W BROADWAY
Mailing Address - Street 2:PO BOX 665
Mailing Address - City:PLAINVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55964-1255
Mailing Address - Country:US
Mailing Address - Phone:507-534-2600
Mailing Address - Fax:
Practice Address - Street 1:323 W BROADWAY
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:MN
Practice Address - Zip Code:55964-1255
Practice Address - Country:US
Practice Address - Phone:507-534-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN491P9COOtherBCBS INDIVIDUAL NUMBER
MN876455000Medicaid