Provider Demographics
NPI:1104601392
Name:COREY, MICHELLE (FMP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:COREY
Suffix:
Gender:F
Credentials:FMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 VISTA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6781
Mailing Address - Country:US
Mailing Address - Phone:575-770-4985
Mailing Address - Fax:866-686-3415
Practice Address - Street 1:509 VISTA RIDGE RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6781
Practice Address - Country:US
Practice Address - Phone:575-770-3695
Practice Address - Fax:866-686-3415
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM66332171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach