Provider Demographics
NPI:1497028401
Name:WILLIAMS, CORNELL
Entity Type:Individual
Prefix:
First Name:CORNELL
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6616 LAVENDER LILLY LN #1
Mailing Address - Street 2:
Mailing Address - City:N. LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084
Mailing Address - Country:US
Mailing Address - Phone:702-917-5101
Mailing Address - Fax:
Practice Address - Street 1:6616 LAVENDER LILLY LN #1
Practice Address - Street 2:
Practice Address - City:N. LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084
Practice Address - Country:US
Practice Address - Phone:702-917-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner