Provider Demographics
NPI:1801204805
Name:CORELLI, WENDY (MS, AT, ATC)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:CORELLI
Suffix:
Gender:F
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15096 OAKLAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2721
Mailing Address - Country:US
Mailing Address - Phone:616-566-7924
Mailing Address - Fax:
Practice Address - Street 1:6191 KRAFT AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-9396
Practice Address - Country:US
Practice Address - Phone:616-871-6186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010007182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer