Healthcare Provider Details

I. General information

NPI: 1477969657
Provider Name (Legal Business Name): KORIE KAE PRAVECEK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KORIE KAE PRAVECEK CNP

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E 8TH ST SUITE 1
WINNER SD
57580-2634
US

IV. Provider business mailing address

28260 318TH AVE
COLOME SD
57528-6412
US

V. Phone/Fax

Practice location:
  • Phone: 605-842-2626
  • Fax:
Mailing address:
  • Phone: 605-840-0166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000870
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: