Provider Demographics
NPI:1780491555
Name:TALAMONTI, CORISSA RENAE
Entity type:Individual
Prefix:
First Name:CORISSA
Middle Name:RENAE
Last Name:TALAMONTI
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 1:5100 FAIRWAY CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9619
Mailing Address - Country:US
Mailing Address - Phone:734-864-2584
Mailing Address - Fax:
Practice Address - Street 1:10639 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-4349
Practice Address - Country:US
Practice Address - Phone:502-933-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004549A152W00000X
KY2423DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist