Basic Information
| Provider Information | |||||||||
| NPI: | 1033662770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORLE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 384 | ||||||||
| Address2: | |||||||||
| City: | WINDBER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159630384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144673637 | ||||||||
| FaxNumber: | 8144673622 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 SCALP AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142544207 | ||||||||
| FaxNumber: | 8142544733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2016 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP016385 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1034749420001 | 05 | PA | MEDICAID |