Provider Demographics
NPI:1053134742
Name:CORNELY, KIMBERLEY M (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:M
Last Name:CORNELY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:M
Other - Last Name:ATHEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 KENT CT
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08051-1731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 KENT CT
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08051-1731
Practice Address - Country:US
Practice Address - Phone:609-790-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15197500363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health