Provider Demographics
NPI:1417373770
Name:KORFIATIS, CAROLYN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:KORFIATIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:NEWCOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0660
Mailing Address - Country:US
Mailing Address - Phone:509-205-1503
Mailing Address - Fax:
Practice Address - Street 1:85 SIERRA PARK RD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2073
Practice Address - Country:US
Practice Address - Phone:509-205-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY672701-1163W00000X
CA95002589363LF0000X
CA95036715163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse