Provider Demographics
NPI:1275340713
Name:CORLISS, MELISA (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:CORLISS
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SCRAPBOOK LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-7950
Mailing Address - Country:US
Mailing Address - Phone:630-514-3194
Mailing Address - Fax:
Practice Address - Street 1:102 SCRAPBOOK LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7950
Practice Address - Country:US
Practice Address - Phone:630-514-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRN.276624R163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant