Provider Demographics
NPI:1215216726
Name:CORNELY, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:CORNELY
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 1:266 OAK ST
Mailing Address - Street 2:APT. #304
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1644
Mailing Address - Country:US
Mailing Address - Phone:716-553-7538
Mailing Address - Fax:
Practice Address - Street 1:625 DELAWARE AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1009
Practice Address - Country:US
Practice Address - Phone:716-884-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY645759-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse