Provider Demographics
NPI:1942954730
Name:CORNETT, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CORNETT
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 1:262 WEST ST REAR B
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1644
Mailing Address - Country:US
Mailing Address - Phone:570-520-9332
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKHILL SQ S
Practice Address - Street 2:
Practice Address - City:SUGARLOAF
Practice Address - State:PA
Practice Address - Zip Code:18249-1016
Practice Address - Country:US
Practice Address - Phone:888-726-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health