Provider Demographics
NPI:1073090965
Name:BORNEMAN, KORI A (FNP)
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:A
Last Name:BORNEMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:3885 W ASHLEY CIR STE F600
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-9273
Practice Address - Country:US
Practice Address - Phone:843-402-1360
Practice Address - Fax:843-402-3309
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22245363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5480Medicaid