Provider Demographics
NPI:1699732461
Name:KORNELY, LISA GUSTINE (DPM)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:GUSTINE
Last Name:KORNELY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2118
Mailing Address - Country:US
Mailing Address - Phone:262-335-2930
Mailing Address - Fax:262-335-2931
Practice Address - Street 1:2358 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2118
Practice Address - Country:US
Practice Address - Phone:262-335-2930
Practice Address - Fax:262-335-2931
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI774-025213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43225400Medicaid
WI43225400Medicaid