Provider Demographics
NPI:1689615825
Name:CORNWELL, CHRISTY MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:MARIE
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:MARIE
Other - Last Name:OSBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2150 S OAKDALE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3012
Mailing Address - Country:US
Mailing Address - Phone:812-345-8485
Mailing Address - Fax:
Practice Address - Street 1:N4175 CO RD KCA
Practice Address - Street 2:
Practice Address - City:BIG BAY
Practice Address - State:MI
Practice Address - Zip Code:49808
Practice Address - Country:US
Practice Address - Phone:906-345-9314
Practice Address - Fax:906-345-9890
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011331225100000X
WI9979-024225100000X
IN05012942A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist