Provider Demographics
NPI:1639347594
Name:CORNETT, CAROL TERESE (FNP-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:TERESE
Last Name:CORNETT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:MITORAJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 COAKLEY LN
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40068-7832
Mailing Address - Country:US
Mailing Address - Phone:502-544-8704
Mailing Address - Fax:
Practice Address - Street 1:111 COAKLEY LN
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:KY
Practice Address - Zip Code:40068-7832
Practice Address - Country:US
Practice Address - Phone:502-544-8704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100075620Medicaid