Provider Demographics
NPI:1053029322
Name:CORNETTE, ANTHONY JOSEPH (AS)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:CORNETTE
Suffix:
Gender:M
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4012
Mailing Address - Country:US
Mailing Address - Phone:781-799-2607
Mailing Address - Fax:
Practice Address - Street 1:1 HARVEST CIR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:MA
Practice Address - Zip Code:01773-3214
Practice Address - Country:US
Practice Address - Phone:781-799-2607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4833224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty