Basic Information
| Provider Information | |||||||||
| NPI: | 1417445321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOERNER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DYKSTRA | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN STE 600C | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1114 E COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463562359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196901048 | ||||||||
| FaxNumber: | 2196901047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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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 | 05013053A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.