Provider Demographics
NPI:1457610719
Name:KORZENEWSKI, LISA B (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:KORZENEWSKI
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 1:16342 N IL HWY 37
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-242-1510
Mailing Address - Fax:618-242-0958
Practice Address - Street 1:16342 N IL HWY 37
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-0054
Practice Address - Country:US
Practice Address - Phone:618-242-1510
Practice Address - Fax:618-242-0958
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.277054163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL237254917005Medicaid
IL970060Medicare PIN