Provider Demographics
NPI:1003537184
Name:CORNELL, TRENDA RENEE
Entity Type:Individual
Prefix:MS
First Name:TRENDA
Middle Name:RENEE
Last Name:CORNELL
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 1:1445 ARATA WAY
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-4505
Mailing Address - Country:US
Mailing Address - Phone:458-224-1045
Mailing Address - Fax:
Practice Address - Street 1:1445 ARATA WAY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4505
Practice Address - Country:US
Practice Address - Phone:458-224-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR519242251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500809241Medicaid