Provider Demographics
NPI:1043817620
Name:CORNELISON, KELLY (PA-C, RT (R))
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:PA-C, RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WENSLEY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3532
Mailing Address - Country:US
Mailing Address - Phone:973-534-4069
Mailing Address - Fax:
Practice Address - Street 1:336 HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-373-3195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8440363A00000X
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program