Provider Demographics
NPI:1124728175
Name:CORRIVEAU, MICHAEL A (LPN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:CORRIVEAU
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-3000
Mailing Address - Country:US
Mailing Address - Phone:904-229-9294
Mailing Address - Fax:
Practice Address - Street 1:1109 GRANBY RD
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-1568
Practice Address - Country:US
Practice Address - Phone:413-213-5668
Practice Address - Fax:413-356-6672
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44404164W00000X
MALN100403164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse