MEDICARE: LISA CORNELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	884126141	NY
2	174400000X	Specialist	883905141	NY
3	174400000X	Specialist	883888141	NY

General Provider Information

NPI Number	:	1770989899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA CORNELL

Provider Business Mailing Address
First Line	:	54 BROWN BLVD
Second Line	:
City	:	WHEATLEY HTS
State	:	NY
Zip	:	11798-1520
Country	:	US
Telephone Number	:	631-478-2262
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 BROWN BLVD
Second Line	:
City	:	WHEATLEY HTS
State	:	NY
Zip	:	11798-1520
Country	:	US
Telephone Number	:	631-478-2262
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	11/17/2014

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Directions to “ LISA CORNELL ” Practice Location

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