Provider Demographics
NPI:1730894890
Name:CORNELL, ALEXANDRA (CCP)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:CORNELL
Suffix:
Gender:F
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 REVERE BEACH PKWY APT 567
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5973
Mailing Address - Country:US
Mailing Address - Phone:330-447-7017
Mailing Address - Fax:
Practice Address - Street 1:1760 REVERE BEACH PKWY APT 567
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5973
Practice Address - Country:US
Practice Address - Phone:330-447-7017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPL2781242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist