Provider Demographics
NPI:1497293187
Name:CORLISS, MARIA (LPN)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:CORLISS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:JAYNE
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:815 W 5TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3810
Practice Address - Country:US
Practice Address - Phone:423-586-5032
Practice Address - Fax:423-581-8473
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN62715164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse