Healthcare Provider Details

I. General information

NPI: 1366736522
Provider Name (Legal Business Name): STACIE MICHELLE GEHRON CORNWELL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 FALLS CREEK DR
VANDALIA OH
45377-8600
US

IV. Provider business mailing address

830 FALLS CREEK DR
VANDALIA OH
45377-8600
US

V. Phone/Fax

Practice location:
  • Phone: 937-890-9235
  • Fax: 937-890-9239
Mailing address:
  • Phone: 937-890-9235
  • Fax: 937-890-9239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT013217
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: