Provider Demographics
NPI:1225410285
Name:KORALESKY, SAMANTHA (LAC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KORALESKY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 288TH AVE
Mailing Address - Street 2:2
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9532
Mailing Address - Country:US
Mailing Address - Phone:262-586-0199
Mailing Address - Fax:
Practice Address - Street 1:7510 288TH AVE
Practice Address - Street 2:2
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-9532
Practice Address - Country:US
Practice Address - Phone:262-586-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI799-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist