Individual
MISS KAJA MADISON KORENKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
IS
Contact information
Practice address
420 CARDINAL DR, SHELLEY, ID 83274-4925
(208) 918-9991
Mailing address
420 CARDINAL DR, SHELLEY, ID 83274-4925
(208) 918-9991
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
GC233125A
DRIVERS LICENSE NUMBER
ID
Enumeration date
07/06/2022
Last updated
07/06/2022
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