Provider Demographics
NPI:1093329740
Name:KORDIE, KERI LYNN ROSE
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:LYNN ROSE
Last Name:KORDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1466 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-9002
Mailing Address - Country:US
Mailing Address - Phone:269-207-0317
Mailing Address - Fax:
Practice Address - Street 1:3238 CAPITAL AVE SW
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-4302
Practice Address - Country:US
Practice Address - Phone:269-979-6432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11022186367A00000X
MICNM06201367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife