Healthcare Provider Details

I. General information

NPI: 1780122937
Provider Name (Legal Business Name): KORTNEY NYMAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 N PROVIDENCE AVE
APPLETON WI
54913-8018
US

IV. Provider business mailing address

3725 S JOHANN DR
APPLETON WI
54915-7066
US

V. Phone/Fax

Practice location:
  • Phone: 920-257-9766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13491146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: