Provider Demographics
NPI:1740912773
Name:LEIST, KORI WYNN
Entity type:Individual
Prefix:
First Name:KORI
Middle Name:WYNN
Last Name:LEIST
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:W6846 APPLETREE CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8006
Mailing Address - Country:US
Mailing Address - Phone:920-428-3627
Mailing Address - Fax:
Practice Address - Street 1:2400 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8728
Practice Address - Country:US
Practice Address - Phone:920-831-5050
Practice Address - Fax:920-738-7648
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist