Provider Demographics
NPI:1013736628
Name:AMILLIDREEM, KOURTKNIE ALEXIS (LMT 3679)
Entity type:Individual
Prefix:
First Name:KOURTKNIE
Middle Name:ALEXIS
Last Name:AMILLIDREEM
Suffix:
Gender:F
Credentials:LMT 3679
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1888 MAIN ST STE 477
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6337
Mailing Address - Country:US
Mailing Address - Phone:601-842-5559
Mailing Address - Fax:
Practice Address - Street 1:1222 OLD FANNIN RD STE D
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8795
Practice Address - Country:US
Practice Address - Phone:601-842-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSLMT3679225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist