Provider Demographics
NPI:1407647506
Name:GUILLETTE, KORT
Entity type:Individual
Prefix:
First Name:KORT
Middle Name:
Last Name:GUILLETTE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3463
Mailing Address - Country:US
Mailing Address - Phone:208-851-8912
Mailing Address - Fax:
Practice Address - Street 1:425 S 19TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3463
Practice Address - Country:US
Practice Address - Phone:208-851-8912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program