Provider Demographics
NPI:1942933239
Name:KORNELLY, ALLISON PAIGE
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:PAIGE
Last Name:KORNELLY
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant