Provider Demographics
NPI:1356005672
Name:WILFLEY, CORBY
Entity Type:Individual
Prefix:
First Name:CORBY
Middle Name:
Last Name:WILFLEY
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 1:1605 ROCKMOOR AVE APT B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-2023
Mailing Address - Country:US
Mailing Address - Phone:512-964-0345
Mailing Address - Fax:
Practice Address - Street 1:1605 ROCKMOOR AVE APT B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-2023
Practice Address - Country:US
Practice Address - Phone:512-964-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83819133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT83819OtherTDLR