Provider Demographics
NPI:1548685365
Name:KORNEGAY, ALICE (LMBT)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:KORNEGAY
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:
Other - Last Name:FASSNACHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMBT
Mailing Address - Street 1:412 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NC
Mailing Address - Zip Code:27569-9301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2837B DAISY LN N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-6942
Practice Address - Country:US
Practice Address - Phone:252-206-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7344173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist