Provider Demographics
NPI:1902114382
Name:CORNEJO, MELANIE ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:ANN
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MELANIE
Other - Middle Name:ANN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 11240
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1240
Mailing Address - Country:US
Mailing Address - Phone:949-793-3400
Mailing Address - Fax:949-612-3821
Practice Address - Street 1:2589 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1311
Practice Address - Country:US
Practice Address - Phone:949-793-3400
Practice Address - Fax:949-612-3821
Is Sole Proprietor?:No
Enumeration Date:2010-09-19
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28458225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist