Provider Demographics
NPI:1366556987
Name:CORNELL, JANINE ELISE (OT)
Entity type:Individual
Prefix:MRS
First Name:JANINE
Middle Name:ELISE
Last Name:CORNELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 LAKE BOONE TRL
Mailing Address - Street 2:STE 4
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7512
Mailing Address - Country:US
Mailing Address - Phone:919-781-4434
Mailing Address - Fax:919-781-5851
Practice Address - Street 1:4201 LAKE BOONE TRL
Practice Address - Street 2:STE 4
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7512
Practice Address - Country:US
Practice Address - Phone:919-781-4434
Practice Address - Fax:919-781-5851
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2508225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1036VOtherBLUE CROSS BLUE SHILD OF
NC7311133Medicaid