Basic Information
| Provider Information | |||||||||
| NPI: | 1740807148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNWELL | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 E 88TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561235 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1341 OHIO ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478073940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124785437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2020 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-125995 | IN | Y |
No ID Information.