Provider Demographics
NPI:1962062042
Name:CORNELL, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CORNELL
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 1:7851 N LEATON RD
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-9135
Mailing Address - Country:US
Mailing Address - Phone:989-560-0618
Mailing Address - Fax:
Practice Address - Street 1:1114 E CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-1853
Practice Address - Country:US
Practice Address - Phone:989-854-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other