Provider Demographics
NPI:1063790640
Name:CORNEJO, DESIRAE
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:CORNEJO
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 1:2 HICKERSON ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-9759
Mailing Address - Country:US
Mailing Address - Phone:307-332-7415
Mailing Address - Fax:
Practice Address - Street 1:2 HICKERSON ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-9759
Practice Address - Country:US
Practice Address - Phone:307-332-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator