Provider Demographics
NPI:1629323605
Name:CORNELL, CARISSA R (NP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:R
Last Name:CORNELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:5615 DUNBARTON AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8216
Mailing Address - Country:US
Mailing Address - Phone:509-222-1275
Mailing Address - Fax:509-491-3031
Practice Address - Street 1:3345 39TH ST S STE 2
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:509-222-1275
Practice Address - Fax:509-491-3031
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2018-07-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NDR34040363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner