Provider Demographics
NPI:1811193931
Name:BOOKER, CORLISS VONCILLE (RN)
Entity Type:Individual
Prefix:DR
First Name:CORLISS
Middle Name:VONCILLE
Last Name:BOOKER
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 1:14101 LYNDHURST DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-8804
Mailing Address - Country:US
Mailing Address - Phone:804-425-5190
Mailing Address - Fax:804-425-5359
Practice Address - Street 1:14101 LYNDHURST DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-8804
Practice Address - Country:US
Practice Address - Phone:804-425-5190
Practice Address - Fax:804-425-5359
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001085795163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator