Healthcare Provider Details

I. General information

NPI: 1073233979
Provider Name (Legal Business Name): MARY CARMEN CORNEJO APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 SPARTA RD
SEBRING FL
33870-6066
US

IV. Provider business mailing address

3735 SPARTA RD
SEBRING FL
33870-6066
US

V. Phone/Fax

Practice location:
  • Phone: 863-449-7908
  • Fax:
Mailing address:
  • Phone: 863-449-7908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11021637
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: