Provider Demographics
NPI:1316256043
Name:BREWINGTON-JOHNSON, CORNELLA RENEE
Entity type:Individual
Prefix:MRS
First Name:CORNELLA
Middle Name:RENEE
Last Name:BREWINGTON-JOHNSON
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 1:50 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-2154
Mailing Address - Country:US
Mailing Address - Phone:631-348-5139
Mailing Address - Fax:
Practice Address - Street 1:50 WHEELER RD
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2154
Practice Address - Country:US
Practice Address - Phone:631-348-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY358039-1163W00000X
NYF381362-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse