Provider Demographics
NPI:1073600482
Name:CORNELL, JUSTINE (CRNA)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:CORNELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LINDA ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-1605
Mailing Address - Country:US
Mailing Address - Phone:814-255-5633
Mailing Address - Fax:
Practice Address - Street 1:600 SOMERSET AVE
Practice Address - Street 2:
Practice Address - City:WINDBER
Practice Address - State:PA
Practice Address - Zip Code:15963-1331
Practice Address - Country:US
Practice Address - Phone:814-467-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA031168367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01965063Medicare ID - Type UnspecifiedPROVIDER NUMBER