Provider Demographics
NPI:1053871160
Name:CORNELL, KATHERINE MARIE (DO)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:CORNELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 GRANGER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-5352
Mailing Address - Country:US
Mailing Address - Phone:802-371-5950
Mailing Address - Fax:
Practice Address - Street 1:246 GRANGER RD STE 1
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-5352
Practice Address - Country:US
Practice Address - Phone:802-371-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT032-0134016208000000X
VT032.1034016208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program