Provider Demographics
NPI:1497572986
Name:MCCLURE, CORISSA
Entity type:Individual
Prefix:
First Name:CORISSA
Middle Name:
Last Name:MCCLURE
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 1:138 E PEELER AVE
Mailing Address - Street 2:STE 277 PMB 1004
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 E PEELER AVE
Practice Address - Street 2:STE 277 PMB 1004
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773
Practice Address - Country:US
Practice Address - Phone:662-931-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS925891163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse