Healthcare Provider Details

I. General information

NPI: 1336572312
Provider Name (Legal Business Name): EDWARD CORNMAN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

IV. Provider business mailing address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-4298
  • Fax: 330-729-1897
Mailing address:
  • Phone: 330-729-4298
  • Fax: 330-729-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP013965
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.14845
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: