Basic Information
| Provider Information | |||||||||
| NPI: | 1790975043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNELLA | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 E ORMAN AVE | ||||||||
| Address2: | A640 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810043537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195641544 | ||||||||
| FaxNumber: | 7195652657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 E ORMAN AVE | ||||||||
| Address2: | A640 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810043537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195641544 | ||||||||
| FaxNumber: | 7195652657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 91303 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.