Healthcare Provider Details

I. General information

NPI: 1659362655
Provider Name (Legal Business Name): JANE K CORNWELL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 W PIERCE ST SUITE 4-A
CARLSBAD NM
88220-3537
US

IV. Provider business mailing address

2402 W PIERCE ST STE 6G
CARLSBAD NM
88220-3566
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-9964
  • Fax: 505-234-9962
Mailing address:
  • Phone: 575-628-0331
  • Fax: 575-628-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR49802
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCNP01235
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: