Provider Demographics
NPI:1114506896
Name:CORNUTT, RACHAEL D (LPN)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:D
Last Name:CORNUTT
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 1:1654 N DANEBO AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-6416
Mailing Address - Country:US
Mailing Address - Phone:541-515-5060
Mailing Address - Fax:
Practice Address - Street 1:1654 N DANEBO AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-6416
Practice Address - Country:US
Practice Address - Phone:541-515-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201701354LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201701354LPNOtherOREGON STATE BOARD OF NURSING