Provider Demographics
NPI:1891073979
Name:GREGG-CORNELL, KIMBERLY N (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:GREGG-CORNELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-395-8805
Mailing Address - Fax:740-395-8855
Practice Address - Street 1:280 PATTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9452
Practice Address - Country:US
Practice Address - Phone:740-395-8852
Practice Address - Fax:740-395-8855
Is Sole Proprietor?:No
Enumeration Date:2011-07-24
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000433620OtherOH MEDICAID UNISON
OH310917085261OtherOHIO MEDICAID CARESOURCE
OH0050776OtherOHIO MEDICAID MOLINA
OH0050776Medicaid
WV3810021365Medicaid
OH310917085261OtherOHIO MEDICAID CARESOURCE