Provider Demographics
NPI:1306387691
Name:CORNEJO, EMILIZA (RN, APRN)
Entity Type:Individual
Prefix:
First Name:EMILIZA
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:RN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 78 BOX 1082
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96326-0011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 ROUTE 3
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6911
Practice Address - Country:US
Practice Address - Phone:671-645-5500
Practice Address - Fax:671-645-5549
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA766723163W00000X
WA60375819163W00000X
GURE2287163W00000X
GUNP0170363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH110140Medicaid