Provider Demographics
NPI:1215549274
Name:CORNEJO, MARIA GRACIELA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:GRACIELA
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 1:3421 S LOBACK LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7913
Mailing Address - Country:US
Mailing Address - Phone:480-980-4181
Mailing Address - Fax:
Practice Address - Street 1:3421 S LOBACK LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7913
Practice Address - Country:US
Practice Address - Phone:480-980-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ246607363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health