Provider Demographics
NPI:1427521681
Name:CORNEJO, ANTHONY RYAN
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RYAN
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 783
Mailing Address - Street 2:
Mailing Address - City:FELDA
Mailing Address - State:FL
Mailing Address - Zip Code:33930-0783
Mailing Address - Country:US
Mailing Address - Phone:863-234-8642
Mailing Address - Fax:
Practice Address - Street 1:90 CYPRESS WAY E STE 60
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-9275
Practice Address - Country:US
Practice Address - Phone:800-210-0814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician