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NPI Code Detail

MEDICARE: CONNIE KORNMAN RN

MEDICARE: CONNIE KORNMAN RN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WA0400XAddiction (Substance Use Disorder) Registered Nurse246480WI

General Provider Information

NPI Number : 1215651195
Entity Type Code : Individual
Provider Name (Legal Business Name) : CONNIE KORNMAN RN
Provider Business Mailing Address
First Line : 3825 39TH AVE STE 120
Second Line :
City : KENOSHA
State : WI
Zip : 53144-2043
Country : US
Telephone Number : 262-946-5752
Fax Number :
Provider Business Practice Location Address
First Line : 3825 39TH AVE STE 120
Second Line :
City : KENOSHA
State : WI
Zip : 53144-2043
Country : US
Telephone Number : 262-946-5752
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/03/2022
Last Update Date : 10/03/2022

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