Provider Demographics
NPI:1578137675
Name:CORRALES, KERRI (RN)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:CORRALES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 POINTE CIR N
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1539
Mailing Address - Country:US
Mailing Address - Phone:631-355-9131
Mailing Address - Fax:
Practice Address - Street 1:2450 N WADING RIVER RD
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-1402
Practice Address - Country:US
Practice Address - Phone:631-929-6200
Practice Address - Fax:631-929-3172
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY774154163WP0807X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent