Provider Demographics
NPI:1386296994
Name:EVANS-CORNISH, MICHELLE (SPECIAL ED)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:EVANS-CORNISH
Suffix:
Gender:F
Credentials:SPECIAL ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13122 223RD ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1646
Mailing Address - Country:US
Mailing Address - Phone:347-613-1585
Mailing Address - Fax:718-525-0799
Practice Address - Street 1:13122 223RD ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1646
Practice Address - Country:US
Practice Address - Phone:347-613-1585
Practice Address - Fax:718-525-0799
Is Sole Proprietor?:No
Enumeration Date:2019-07-13
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist