Provider Demographics
NPI:1235840901
Name:CORNAVACA, LORENA
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:CORNAVACA
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:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-596-3876
Mailing Address - Fax:786-533-9989
Practice Address - Street 1:6200 SUNSET DR STE 130
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4832
Practice Address - Country:US
Practice Address - Phone:786-596-3876
Practice Address - Fax:786-533-9989
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11022648363L00000X
FL11022648363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner