Provider Demographics
NPI:1477969657
Name:PRAVECEK, KORIE KAE (CNP)
Entity Type:Individual
Prefix:
First Name:KORIE
Middle Name:KAE
Last Name:PRAVECEK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KORIE
Other - Middle Name:KAE
Other - Last Name:PRAVECEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNP
Mailing Address - Street 1:28260 318TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLOME
Mailing Address - State:SD
Mailing Address - Zip Code:57528-6412
Mailing Address - Country:US
Mailing Address - Phone:605-840-0166
Mailing Address - Fax:
Practice Address - Street 1:825 E 8TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-2634
Practice Address - Country:US
Practice Address - Phone:605-842-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000870363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily