Provider Demographics
NPI:1851649263
Name:CORNELISSEN-WIED, KARI ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KARI
Middle Name:ANN
Last Name:CORNELISSEN-WIED
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1826
Mailing Address - Country:US
Mailing Address - Phone:920-388-3440
Mailing Address - Fax:920-388-4560
Practice Address - Street 1:1218 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1826
Practice Address - Country:US
Practice Address - Phone:920-388-3440
Practice Address - Fax:920-388-4560
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4793-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor