Healthcare Provider Details

I. General information

NPI: 1790975043
Provider Name (Legal Business Name): PAMELA JOY CORNELLA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 E ORMAN AVE A640
PUEBLO CO
81004-3537
US

IV. Provider business mailing address

1925 E ORMAN AVE A640
PUEBLO CO
81004-3537
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-1544
  • Fax: 719-565-2657
Mailing address:
  • Phone: 719-564-1544
  • Fax: 719-565-2657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number91303
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: