Provider Demographics
NPI:1073863429
Name:CORNETT, JENNIFER RENEE (LPN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:CORNETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 PORTAGE RD
Mailing Address - Street 2:APT #3
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14303-1421
Mailing Address - Country:US
Mailing Address - Phone:716-578-0482
Mailing Address - Fax:
Practice Address - Street 1:445 PORTAGE RD
Practice Address - Street 2:APT #3
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14303-1421
Practice Address - Country:US
Practice Address - Phone:716-578-0482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10-287937164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse