Basic Information
| Provider Information | |||||||||
| NPI: | 1720131634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORSBERG | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6727 RANGER DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336152530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138555259 | ||||||||
| FaxNumber: | 7277674715 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 6TH AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674403 | ||||||||
| FaxNumber: | 7277674715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 03/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 163WP0200X | ARNP960292 | FL | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0200X | 0960292 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 311185700 | 05 | FL | MEDICAID | 303292200 | 05 | FL | MEDICAID | 811643100 | 05 | FL | MEDICAID |