Provider Demographics
NPI:1275225906
Name:WETTLAUFER, CORINA MARIE
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:MARIE
Last Name:WETTLAUFER
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 1:5979 DESERT STORM AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5514
Mailing Address - Country:US
Mailing Address - Phone:270-412-1234
Mailing Address - Fax:270-461-0430
Practice Address - Street 1:5979 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5514
Practice Address - Country:US
Practice Address - Phone:270-412-1234
Practice Address - Fax:270-461-0430
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator