Provider Demographics
NPI:1871896829
Name:KORNETZ, NIKKI MICHELLE (LPN)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:MICHELLE
Last Name:KORNETZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:MICHELLE
Other - Last Name:MAURER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2814 ARGONNE LN S
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1286
Mailing Address - Country:US
Mailing Address - Phone:937-408-1331
Mailing Address - Fax:
Practice Address - Street 1:2814 ARGONNE LN S
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1286
Practice Address - Country:US
Practice Address - Phone:937-408-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.125113-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse