MEDICARE: PAMELA S CORNELL

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	163WI0500X	Infusion Therapy Registered Nurse	508565	CA

General Provider Information

NPI Number	:	1457800112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA S CORNELL

Provider Business Mailing Address
First Line	:	PO BOX 562
Second Line	:
City	:	MOUNTAIN RANCH
State	:	CA
Zip	:	95246-0562
Country	:	US
Telephone Number	:	209-754-5563
Fax Number	:	209-754-5563

Provider Business Practice Location Address
First Line	:	18268 PINE BARK LN
Second Line	:
City	:	MOKELUMNE HILL
State	:	CA
Zip	:	95245-9654
Country	:	US
Telephone Number	:	209-754-5563
Fax Number	:	209-754-5563

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

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	09/22/2016

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