Basic Information
| Provider Information | |||||||||
| NPI: | 1225636749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNWALL | ||||||||
| FirstName: | GINA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 337 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117574519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314556730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117012508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312644000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2020 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | F403129-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.