Provider Demographics
NPI:1134306350
Name:CORNELL, NIKKI SARAH (PT)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:SARAH
Last Name:CORNELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N PEACH AVE STE G14
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-7264
Mailing Address - Country:US
Mailing Address - Phone:559-433-4700
Mailing Address - Fax:
Practice Address - Street 1:755 N PEACH AVE STE G14
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-7264
Practice Address - Country:US
Practice Address - Phone:559-433-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25933225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist