Provider Demographics
NPI:1043211428
Name:CORNELL, AMIE J (CRNA)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:J
Last Name:CORNELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMIE
Other - Middle Name:J
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:100 MALLARD CREEK RD STE 320
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-5136
Mailing Address - Country:US
Mailing Address - Phone:502-690-8782
Mailing Address - Fax:502-459-0923
Practice Address - Street 1:100 MALLARD CREEK RD STE 320
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5136
Practice Address - Country:US
Practice Address - Phone:502-690-8782
Practice Address - Fax:502-459-0923
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1085051163W00000X
KY3004739367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100030510OtherKENTUCKY MEDICAID
KYK066250OtherMEDICARE PTAN