Provider Demographics
NPI:1538904032
Name:KORTEKAAS, ALICE R
Entity type:Individual
Prefix:MISS
First Name:ALICE
Middle Name:R
Last Name:KORTEKAAS
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 215
Mailing Address - Street 2:
Mailing Address - City:MEADOWLANDS
Mailing Address - State:MN
Mailing Address - Zip Code:55765-0215
Mailing Address - Country:US
Mailing Address - Phone:218-892-5195
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 215
Practice Address - Street 2:
Practice Address - City:MEADOWLANDS
Practice Address - State:MN
Practice Address - Zip Code:55765-0215
Practice Address - Country:US
Practice Address - Phone:218-892-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN376J00000X376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty