Provider Demographics
NPI:1689257628
Name:KORNBURGER, CHERYL (RN)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:KORNBURGER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N113W16241 SYLVAN CIR UNIT 216
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6037
Mailing Address - Country:US
Mailing Address - Phone:414-839-9255
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI158788-30163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Single Specialty