Provider Demographics
NPI:1417764887
Name:KORTBAOUI, SUMMER
Entity type:Individual
Prefix:
First Name:SUMMER
Middle Name:
Last Name:KORTBAOUI
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 1:1591 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-1533
Mailing Address - Country:US
Mailing Address - Phone:908-451-6187
Mailing Address - Fax:
Practice Address - Street 1:1591 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-1533
Practice Address - Country:US
Practice Address - Phone:908-451-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK189948163WX0002X
CA95245061163WX0002X
NJ26NR21272100163WX0002X
PARN698111163WX0002X
TX1087818163WX0002X
NY771010163WX0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk