Provider Demographics
NPI:1912365750
Name:KORN, AMY (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KORN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT 5300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:616-242-0300
Mailing Address - Fax:
Practice Address - Street 1:2120 43RD ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508
Practice Address - Country:US
Practice Address - Phone:616-281-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist