Provider Demographics
NPI:1952068652
Name:CORNWELL, KNEKO
Entity Type:Individual
Prefix:
First Name:KNEKO
Middle Name:
Last Name:CORNWELL
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 1:240 E APACHE ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-3702
Mailing Address - Country:US
Mailing Address - Phone:918-794-0197
Mailing Address - Fax:918-794-0196
Practice Address - Street 1:240 E APACHE ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-3702
Practice Address - Country:US
Practice Address - Phone:918-794-0197
Practice Address - Fax:918-794-0196
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health