Healthcare Provider Details

I. General information

NPI: 1699002709
Provider Name (Legal Business Name): DENISE MARY CORNELL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

939 COUNTY ROAD 150 E
WYOMING IL
61491-9615
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2000
  • Fax:
Mailing address:
  • Phone: 309-493-5891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number209007863
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: