Provider Demographics
NPI:1740779644
Name:KORNELIS, ANDREA NICCOLE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICCOLE
Last Name:KORNELIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 18TH AVE SE APT 55
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6613
Mailing Address - Country:US
Mailing Address - Phone:707-450-7587
Mailing Address - Fax:
Practice Address - Street 1:400 18TH AVE SE APT 55
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6613
Practice Address - Country:US
Practice Address - Phone:707-450-7587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-44631103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO106S00000XOtherBEHAVIORAL HEALTH