Provider Demographics
NPI:1720495005
Name:CORNWELL, KAYLA BROBECK
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:BROBECK
Last Name:CORNWELL
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 1:423 FAIRGROUNDS RD APT 6
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4372
Mailing Address - Country:US
Mailing Address - Phone:423-552-5188
Mailing Address - Fax:
Practice Address - Street 1:629 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-5401
Practice Address - Country:US
Practice Address - Phone:423-552-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN136058174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist