Provider Demographics
NPI:1629834080
Name:SPALDING, CORINA KAY
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:KAY
Last Name:SPALDING
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 1:210 KINGS DR W
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3523
Mailing Address - Country:US
Mailing Address - Phone:269-362-0252
Mailing Address - Fax:
Practice Address - Street 1:210 KINGS DR W
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3523
Practice Address - Country:US
Practice Address - Phone:269-362-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86359925133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty