=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053134742
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLEY M CORNELY PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2024
-----------------------------------------------------
Last Update Date | 01/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PO BOX 14
-----------------------------------------------------
City | MANTUA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08051-0014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-446-5632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 KENT CT
-----------------------------------------------------
City | WEST DEPTFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08051-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ15197500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------