Provider Demographics
NPI:1659920049
Name:CORNEJO, CAROL JEAN
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:JEAN
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6528 HERITAGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406
Mailing Address - Country:US
Mailing Address - Phone:262-260-8300
Mailing Address - Fax:
Practice Address - Street 1:6528 HERITAGE AVENUE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider