Provider Demographics
NPI:1376046441
Name:VANDERVALL, KORINN KORVETTE
Entity Type:Individual
Prefix:
First Name:KORINN
Middle Name:KORVETTE
Last Name:VANDERVALL
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 1:1363 W BRAYMORE CIR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8290
Mailing Address - Country:US
Mailing Address - Phone:630-806-5662
Mailing Address - Fax:
Practice Address - Street 1:111 NORTH WASHINGTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1841
Practice Address - Country:US
Practice Address - Phone:570-343-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program