Provider Demographics
NPI:1790375087
Name:WELLS, CORINNA
Entity Type:Individual
Prefix:
First Name:CORINNA
Middle Name:
Last Name:WELLS
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 1:154 HOWES RUN RD APT 1
Mailing Address - Street 2:
Mailing Address - City:SARVER
Mailing Address - State:PA
Mailing Address - Zip Code:16055-9600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:TARENTUM
Practice Address - State:PA
Practice Address - Zip Code:15084-2004
Practice Address - Country:US
Practice Address - Phone:724-496-9018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI003955225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant