Provider Demographics
NPI:1619219102
Name:KORN, MICHELLE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:KORN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 LARIMORE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-6226
Mailing Address - Country:US
Mailing Address - Phone:816-728-8235
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:816-728-8235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY301433208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics