Provider Demographics
NPI:1013672187
Name:CORNWELL, DANILLE RAVEN
Entity Type:Individual
Prefix:
First Name:DANILLE
Middle Name:RAVEN
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 1:400 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2813
Mailing Address - Country:US
Mailing Address - Phone:631-833-6581
Mailing Address - Fax:
Practice Address - Street 1:400 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2813
Practice Address - Country:US
Practice Address - Phone:631-833-6581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist