Basic Information
| Provider Information | |||||||||
| NPI: | 1992198451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNACCHIONE | ||||||||
| FirstName: | GINA | ||||||||
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| Credential: | OTR/L, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 171 SANFORD ST | ||||||||
| Address2: | |||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920241503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129529726 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4445 EASTGATE MALL STE 103 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584507118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2015 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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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 | 225X00000X | 13901 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 42515 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.