Provider Demographics
NPI:1932659448
Name:CORNELL, NICOLE ALICIA (AT, ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALICIA
Last Name:CORNELL
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 JEFFERSON ST
Mailing Address - Street 2:APARTMENT 11
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3967
Mailing Address - Country:US
Mailing Address - Phone:906-280-5426
Mailing Address - Fax:
Practice Address - Street 1:555 COUNTY ROAD HQ
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-8855
Practice Address - Country:US
Practice Address - Phone:906-225-5044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL5320662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer