Basic Information
| Provider Information | |||||||||
| NPI: | 1629514534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNWELL | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | MARTIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCOTT | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 744786 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048342450 | ||||||||
| FaxNumber: | 7046715331 | ||||||||
| Practice Location | |||||||||
| Address1: | 258 E GARRISON BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280540460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048655838 | ||||||||
| FaxNumber: | 7048650590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2017 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 146463 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | 146463 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 146463 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | 146463 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.