Provider Demographics
NPI:1578691036
Name:CORNWALL, KELLI JEAN (CFA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JEAN
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 CURTISIAN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-0109
Mailing Address - Country:US
Mailing Address - Phone:208-367-2834
Mailing Address - Fax:208-367-4227
Practice Address - Street 1:6140 CURTISIAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0109
Practice Address - Country:US
Practice Address - Phone:208-367-2834
Practice Address - Fax:208-367-4227
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID86169246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDSA024OtherBLUE CROSS