Provider Demographics
NPI:1629107396
Name:FUENTES, KORINNE KJAR (CNM)
Entity Type:Individual
Prefix:MRS
First Name:KORINNE
Middle Name:KJAR
Last Name:FUENTES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-1330
Mailing Address - Country:US
Mailing Address - Phone:435-851-2406
Mailing Address - Fax:435-462-2509
Practice Address - Street 1:1100 S MEDICAL DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-2222
Practice Address - Country:US
Practice Address - Phone:435-851-2406
Practice Address - Fax:435-462-2509
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT195187-4402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5019Medicare UPIN