Provider Demographics
NPI:1588279434
Name:JAMES, KOURTNEY
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:JAMES
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 1:715 LORI DR APT 304
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-7104
Mailing Address - Country:US
Mailing Address - Phone:772-267-8759
Mailing Address - Fax:
Practice Address - Street 1:715 LORI DR APT 304
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-7104
Practice Address - Country:US
Practice Address - Phone:772-267-8759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL1282037224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ520512896770Medicaid