Provider Demographics
NPI:1598743924
Name:CORNETT, KRISTINE LAUBHAN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LAUBHAN
Last Name:CORNETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:LEE
Other - Last Name:LAUBHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:P T
Mailing Address - Street 1:368 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-2202
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist