Healthcare Provider Details

I. General information

NPI: 1346940186
Provider Name (Legal Business Name): MAKAYLA CORNWELL-YOUNG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAKAYLA CORNWELL OD

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 MONTICELLO AVE STE 201
WILLIAMSBURG VA
23188-8221
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 757-259-6823
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003260
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: