MEDICARE: DR. NICOLE CORNISH DNP, APRN-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	89710	OK
2	363LG0600X	Gerontology Nurse Practitioner	89710	OK
3	363LP2300X	Primary Care Nurse Practitioner	89710	OK

General Provider Information

NPI Number	:	1003296492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE CORNISH DNP, APRN-C

Provider Business Mailing Address
First Line	:	3400 S DOUGLAS BLVD
Second Line	:	SUITE 305
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73150-1001
Country	:	US
Telephone Number	:	405-622-3063
Fax Number	:	405-732-0022

Provider Business Practice Location Address
First Line	:	3400 S DOUGLAS BLVD
Second Line	:	SUITE 305
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73150-1001
Country	:	US
Telephone Number	:	405-622-3063
Fax Number	:	405-732-0022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2015
Last Update Date	:	09/19/2016

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