Provider Demographics
NPI:1235343351
Name:KORNKVEN, MICHELLE RENEE (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:KORNKVEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 COUNTY ROAD 4
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-8860
Mailing Address - Country:US
Mailing Address - Phone:701-352-3790
Mailing Address - Fax:
Practice Address - Street 1:108 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DRAYTON
Practice Address - State:ND
Practice Address - Zip Code:58225-4413
Practice Address - Country:US
Practice Address - Phone:701-454-3324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND38235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND38OtherND STATE BOARD OF EXAMINE
ND58570Medicaid