Provider Demographics
NPI:1962556563
Name:CORNWALL, SANDRA MEGAN (QMHA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MEGAN
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9205 SE SALMON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2119
Mailing Address - Country:US
Mailing Address - Phone:971-409-9113
Mailing Address - Fax:
Practice Address - Street 1:945 NE 165TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6148
Practice Address - Country:US
Practice Address - Phone:971-409-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion