Provider Demographics
NPI:1912546177
Name:KORSNESS, KEELIE (MSC, RDN, LD)
Entity Type:Individual
Prefix:
First Name:KEELIE
Middle Name:
Last Name:KORSNESS
Suffix:
Gender:F
Credentials:MSC, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26760 FUDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALSEA
Mailing Address - State:OR
Mailing Address - Zip Code:97324-9412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 SW MADISON AVE STE 109
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4728
Practice Address - Country:US
Practice Address - Phone:545-190-8731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10192004133V00000X
86017100133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered