Provider Demographics
NPI:1457037558
Name:CORNELL, QUINCY JADE
Entity Type:Individual
Prefix:
First Name:QUINCY
Middle Name:JADE
Last Name:CORNELL
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 1:663 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-1637
Mailing Address - Country:US
Mailing Address - Phone:415-203-6169
Mailing Address - Fax:
Practice Address - Street 1:1225 W 190TH STREET SUITE 280
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-2820
Practice Address - Country:US
Practice Address - Phone:877-515-8113
Practice Address - Fax:877-538-2102
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023914363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty