Provider Demographics
NPI:1508189317
Name:CORNWELL, HOLLY JEAN (RN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEAN
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N GRAHAM ST
Mailing Address - Street 2:SUITE 375
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1654
Mailing Address - Country:US
Mailing Address - Phone:503-413-1600
Mailing Address - Fax:503-413-1915
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:SUITE 375
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1654
Practice Address - Country:US
Practice Address - Phone:503-413-1600
Practice Address - Fax:503-413-1915
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200841070RN163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator