Healthcare Provider Details

I. General information

NPI: 1003246315
Provider Name (Legal Business Name): LUAMY GABRIELA CORNEJO PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 BROCKTON AVE STE 100
RIVERSIDE CA
92501-4026
US

IV. Provider business mailing address

24933 PROSPECT AVE
LOMA LINDA CA
92354-2811
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-1293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNP95000040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: