Provider Demographics
NPI:1063008779
Name:CORNELISON, HALI MARIE (DPH)
Entity Type:Individual
Prefix:DR
First Name:HALI
Middle Name:MARIE
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2119
Mailing Address - Country:US
Mailing Address - Phone:580-924-2903
Mailing Address - Fax:580-924-7337
Practice Address - Street 1:1231 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2119
Practice Address - Country:US
Practice Address - Phone:580-924-2903
Practice Address - Fax:580-924-7337
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14898183500000X
TX52594183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist