Provider Demographics
NPI:1285985002
Name:KORNILKIN, JULIE (LICENSED MASSAGE THE)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:KORNILKIN
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9021 S. GIBSON RD.
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038
Mailing Address - Country:US
Mailing Address - Phone:503-951-7082
Mailing Address - Fax:503-263-1185
Practice Address - Street 1:9021 S. GIBSON RD.
Practice Address - Street 2:BLDG. B
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038
Practice Address - Country:US
Practice Address - Phone:503-951-7082
Practice Address - Fax:503-263-1185
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11296225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist