Provider Demographics
NPI:1346029725
Name:CHURCH, CORY DEAN (PHD, RN)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:DEAN
Last Name:CHURCH
Suffix:
Gender:M
Credentials:PHD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:76050-2100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:TX
Practice Address - Zip Code:76050-2100
Practice Address - Country:US
Practice Address - Phone:806-781-8586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX771558163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse