Provider Demographics
NPI:1588317911
Name:LUNDBERG, CORRIE JO
Entity type:Individual
Prefix:
First Name:CORRIE
Middle Name:JO
Last Name:LUNDBERG
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 1:100 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-8426
Mailing Address - Country:US
Mailing Address - Phone:616-600-2052
Mailing Address - Fax:
Practice Address - Street 1:100 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-8426
Practice Address - Country:US
Practice Address - Phone:616-600-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-03-08
Deactivation Date:2022-02-08
Deactivation Code:
Reactivation Date:2022-03-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician