Provider Demographics
NPI:1184127813
Name:CORVALLIS, MICHELLE LYNETTE (DC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNETTE
Last Name:CORVALLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SOUTH FRANKLIN ST.
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640
Mailing Address - Country:US
Mailing Address - Phone:573-915-5200
Mailing Address - Fax:
Practice Address - Street 1:17 SOUTH FRANKLIN ST.
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-915-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018001378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor