Provider Demographics
NPI:1457800112
Name:CORNELL, PAMELA S
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
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:PO BOX 562
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:95246-0562
Mailing Address - Country:US
Mailing Address - Phone:209-754-5563
Mailing Address - Fax:209-754-5563
Practice Address - Street 1:18268 PINE BARK LN
Practice Address - Street 2:
Practice Address - City:MOKELUMNE HILL
Practice Address - State:CA
Practice Address - Zip Code:95245-9654
Practice Address - Country:US
Practice Address - Phone:209-754-5563
Practice Address - Fax:209-754-5563
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA508565163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy