Provider Demographics
NPI:1992198451
Name:CORNACCHIONE, GINA (OTR/L, DPT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CORNACCHIONE
Suffix:
Gender:F
Credentials:OTR/L, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 SANFORD ST
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1503
Mailing Address - Country:US
Mailing Address - Phone:412-952-9726
Mailing Address - Fax:
Practice Address - Street 1:4445 EASTGATE MALL STE 103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1979
Practice Address - Country:US
Practice Address - Phone:858-450-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13901225X00000X
CA42515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist