Healthcare Provider Details

I. General information

NPI: 1962062042
Provider Name (Legal Business Name): AMANDA CORNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 E CHIPPEWA ST
MT PLEASANT MI
48858-1853
US

IV. Provider business mailing address

7851 N LEATON RD
CLARE MI
48617-9135
US

V. Phone/Fax

Practice location:
  • Phone: 989-854-1711
  • Fax:
Mailing address:
  • Phone: 989-560-0618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: