Provider Demographics
NPI:1346002433
Name:CORNETTA, AMANDA ROSE (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:CORNETTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PASTURE RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE STATION
Mailing Address - State:NJ
Mailing Address - Zip Code:08889-3358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5285
Practice Address - Country:US
Practice Address - Phone:571-231-1803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ39020000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program