Provider Demographics
NPI:1447511761
Name:CORNWELL, NICOLE HEBERT (MS)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:HEBERT
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 W 238TH ST APT 3F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-2027
Mailing Address - Country:US
Mailing Address - Phone:207-232-8723
Mailing Address - Fax:
Practice Address - Street 1:474 W 238TH ST APT 3F
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-2027
Practice Address - Country:US
Practice Address - Phone:207-232-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017479225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist