Provider Demographics
NPI:1336541234
Name:CORNWELL, KERRI (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-4503
Mailing Address - Country:US
Mailing Address - Phone:918-366-2281
Mailing Address - Fax:
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-4503
Practice Address - Country:US
Practice Address - Phone:918-366-2281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3128235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist