Basic Information
Provider Information | |||||||||
NPI: | 1295731180 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAMUTH | ||||||||
FirstName: | CORI | ||||||||
MiddleName: | O | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OREM | ||||||||
OtherFirstName: | CORI | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 6350 CENTER DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235024107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572135700 | ||||||||
FaxNumber: | 7572135701 | ||||||||
Practice Location | |||||||||
Address1: | 5900 LAKE WRIGHT DR | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235021871 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574668683 | ||||||||
FaxNumber: | 7574660250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2005 | ||||||||
LastUpdateDate: | 01/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 000166375 | VA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 0024166494 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 94929 | 01 | VA | OPTIMA | OTHER |