Provider Demographics
NPI:1073233979
Name:CORNEJO, MARY CARMEN (APRN-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CARMEN
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3735 SPARTA RD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-6066
Mailing Address - Country:US
Mailing Address - Phone:863-449-7908
Mailing Address - Fax:
Practice Address - Street 1:3735 SPARTA RD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-6066
Practice Address - Country:US
Practice Address - Phone:863-449-7908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily