Provider Demographics
NPI:1134455819
Name:GORDON-CORNWALL, DAINIELLE PETRINA (DPT)
Entity type:Individual
Prefix:DR
First Name:DAINIELLE
Middle Name:PETRINA
Last Name:GORDON-CORNWALL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 TAFT ST STE 303
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1956
Mailing Address - Country:US
Mailing Address - Phone:954-648-5565
Mailing Address - Fax:305-489-0182
Practice Address - Street 1:12251 TAFT ST STE 303
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:954-648-5565
Practice Address - Fax:305-489-0182
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 25081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT 25081OtherPT STATE LICENSE