Provider Demographics
NPI:1255868774
Name:CORNWELL, STACIE MICHELLE (MSED)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MICHELLE
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-6874
Mailing Address - Country:US
Mailing Address - Phone:501-481-8930
Mailing Address - Fax:501-408-4699
Practice Address - Street 1:1306 MILITARY RD STE 1
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2732
Practice Address - Country:US
Practice Address - Phone:501-481-8930
Practice Address - Fax:501-408-4699
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist