Provider Demographics
NPI:1063764967
Name:CORN, VICKI
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:CORN
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 1:122 DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2409
Mailing Address - Country:US
Mailing Address - Phone:770-564-3784
Mailing Address - Fax:
Practice Address - Street 1:122 DAVIS DR
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2409
Practice Address - Country:US
Practice Address - Phone:770-564-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator