Provider Demographics
NPI:1104711167
Name:CORNEJO, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CORNEJO
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 1:6064 WOODHAVEN AVE APT SUITE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1041
Mailing Address - Country:US
Mailing Address - Phone:916-749-6613
Mailing Address - Fax:
Practice Address - Street 1:631 RIVER OAKS PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-1907
Practice Address - Country:US
Practice Address - Phone:408-914-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician