Provider Demographics
NPI:1598534182
Name:YOUNGBLOOD, CORINA RENEE (RN)
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:RENEE
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CORINA
Other - Middle Name:RENEE
Other - Last Name:TATUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3841 PORTER LN
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-5156
Mailing Address - Country:US
Mailing Address - Phone:214-998-6165
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-990-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX811867163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency