Healthcare Provider Details

I. General information

NPI: 1184492415
Provider Name (Legal Business Name): KLARYSSA YOLANDA CORNEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13550 S ROUTE 30 STE 204E
PLAINFIELD IL
60544-5688
US

IV. Provider business mailing address

13550 S ROUTE 30 STE 204E
PLAINFIELD IL
60544-5688
US

V. Phone/Fax

Practice location:
  • Phone: 815-308-2322
  • Fax:
Mailing address:
  • Phone: 815-308-2322
  • Fax: 844-991-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: