Provider Demographics
NPI:1184607533
Name:CORNISH, VICTORIA (ARNP)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:CORNISH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1725
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33802-1725
Mailing Address - Country:US
Mailing Address - Phone:863-683-5454
Mailing Address - Fax:863-683-4652
Practice Address - Street 1:515 E GARDEN ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4615
Practice Address - Country:US
Practice Address - Phone:863-683-5454
Practice Address - Fax:863-683-4652
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1016972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303028800Medicaid
FL214754OtherAMERIGROUP
FL214754OtherAMERIGROUP