Provider Demographics
NPI:1659362655
Name:CORNWELL, JANE K (CNP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:K
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 W PIERCE ST STE 6G
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3566
Mailing Address - Country:US
Mailing Address - Phone:575-628-0331
Mailing Address - Fax:575-628-0332
Practice Address - Street 1:2402 W PIERCE ST
Practice Address - Street 2:SUITE 4-A
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3537
Practice Address - Country:US
Practice Address - Phone:505-234-9964
Practice Address - Fax:505-234-9962
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR49802363LA2200X
NMCNP01235363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43580874Medicaid
NMP32070Medicare UPIN