Healthcare Provider Details

I. General information

NPI: 1942725825
Provider Name (Legal Business Name): AMBER L KORNELY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMBER L THOR F-NP

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 COMMANCHE AVE
GREEN BAY WI
54313-5751
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-435-8326
  • Fax:
Mailing address:
  • Phone: 920-445-7226
  • Fax: 920-445-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7880-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: