Healthcare Provider Details

I. General information

NPI: 1396311270
Provider Name (Legal Business Name): ALLISON KORNOELJE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3152 PEREGRINE DR NE STE 115
GRAND RAPIDS MI
49525-9723
US

IV. Provider business mailing address

10336 SENTRY RD
ZEELAND MI
49464-2095
US

V. Phone/Fax

Practice location:
  • Phone: 616-643-0833
  • Fax:
Mailing address:
  • Phone: 616-405-5750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501013489
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: