Provider Demographics
NPI:1871823484
Name:CORNELL, THERESA P
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:P
Last Name:CORNELL
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 1:10457 SHELLY RD
Mailing Address - Street 2:
Mailing Address - City:THORNVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43076-9385
Mailing Address - Country:US
Mailing Address - Phone:740-323-2232
Mailing Address - Fax:
Practice Address - Street 1:10457 SHELLY RD
Practice Address - Street 2:
Practice Address - City:THORNVILLE
Practice Address - State:OH
Practice Address - Zip Code:43076-9385
Practice Address - Country:US
Practice Address - Phone:740-323-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN067971164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse