Healthcare Provider Details

I. General information

NPI: 1144909045
Provider Name (Legal Business Name): NICOLE MARIE CORNETT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6438 WILMINGTON PIKE STE 230
CENTERVILLE OH
45459-7021
US

IV. Provider business mailing address

12400 HEMPLE RD
FARMERSVILLE OH
45325-8208
US

V. Phone/Fax

Practice location:
  • Phone: 937-558-3810
  • Fax: 937-558-3811
Mailing address:
  • Phone: 937-477-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13268
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: