1619954260 NPI number — MRS. NANCY ANN CORNETT PA-C

Table of content: MRS. NANCY ANN CORNETT PA-C (NPI 1619954260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619954260 NPI number — MRS. NANCY ANN CORNETT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNETT
Provider First Name:
NANCY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KING
Provider Other First Name:
NANCY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619954260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6370 MIDNIGHT COVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34242-3453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-614-1212
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2830 BEE RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34239-7115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-927-1234
Provider Business Practice Location Address Fax Number:
941-921-0043
Provider Enumeration Date:
12/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA9102674 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102282100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com