Healthcare Provider Details

I. General information

NPI: 1932271913
Provider Name (Legal Business Name): CORY CUNNINGHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15901 CICERO AVE
OAK FOREST IL
60452-4005
US

IV. Provider business mailing address

14707 LE CLAIRE AVE
MIDLOTHIAN IL
60445-3570
US

V. Phone/Fax

Practice location:
  • Phone: 708-633-1968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-001648
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: