Provider Demographics
NPI:1497643357
Name:KORNGABLE, OLIVIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:KORNGABLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LIV
Other - Middle Name:
Other - Last Name:KORNGABLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2740 FAIRVIEW AVE N UNIT 319
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1370
Mailing Address - Country:US
Mailing Address - Phone:507-923-0797
Mailing Address - Fax:
Practice Address - Street 1:1570 BEAM AVE STE 300
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-3142
Practice Address - Country:US
Practice Address - Phone:651-232-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist