Basic Information
| Provider Information | |||||||||
| NPI: | 1205912458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORNETT | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 COURT DRIVE | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048247800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2675 COURT DRIVE | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048247800 | ||||||||
| FaxNumber: | 7048242853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3757 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1148 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 720132B | 05 | NC | MEDICAID |