Provider Demographics
NPI:1467003293
Name:CORNEJO, CHRISTINA
Entity Type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:
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 1:1528 MAIN ST # A
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-9422
Mailing Address - Country:US
Mailing Address - Phone:760-997-5048
Mailing Address - Fax:
Practice Address - Street 1:2306 CHRISTI AVE
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-8834
Practice Address - Country:US
Practice Address - Phone:443-480-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA6427201OtherDRIVER LICENSE