Provider Demographics
NPI:1336371269
Name:CORNELL, TERRAH L (FNP)
Entity Type:Individual
Prefix:
First Name:TERRAH
Middle Name:L
Last Name:CORNELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TERRAH
Other - Middle Name:L
Other - Last Name:PATCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:114 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:IL
Mailing Address - Zip Code:61427-5062
Mailing Address - Country:US
Mailing Address - Phone:309-202-6780
Mailing Address - Fax:
Practice Address - Street 1:114 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:IL
Practice Address - Zip Code:61427
Practice Address - Country:US
Practice Address - Phone:309-202-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007698363L00000X
IL277000357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP #
IL809840051OtherMEDICARE INDIVIDUAL #