Basic Information
| Provider Information | |||||||||
| NPI: | 1740382829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORNEGAY | ||||||||
| FirstName: | ASHA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5827 CORPORATE WAY | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5614729692 | ||||||||
| Practice Location | |||||||||
| Address1: | 15858 SW WARFIELD BLVD. | ||||||||
| Address2: | |||||||||
| City: | INDIANTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349560648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725973596 | ||||||||
| FaxNumber: | 8445424898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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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 | 363LP0200X | 2147212 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 306528600 | 05 | FL | MEDICAID |