Provider Demographics
NPI:1326810417
Name:SPACKMAN, CORISSA SUE (CNS, LDN, NBC-HWC)
Entity type:Individual
Prefix:MS
First Name:CORISSA
Middle Name:SUE
Last Name:SPACKMAN
Suffix:
Gender:F
Credentials:CNS, LDN, NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 N GOULD ST STE R
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6317
Mailing Address - Country:US
Mailing Address - Phone:307-314-4467
Mailing Address - Fax:
Practice Address - Street 1:32 N GOULD ST STE R
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6317
Practice Address - Country:US
Practice Address - Phone:307-343-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX6913133N00000X
133NN1002X, 133N00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171400000XOther Service ProvidersHealth & Wellness Coach