Provider Demographics
NPI:1073150090
Name:CORNELIUS, DAKOTA ROSE
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:ROSE
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18540 E SAN TAN BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-2203
Mailing Address - Country:US
Mailing Address - Phone:480-677-8202
Mailing Address - Fax:480-677-8203
Practice Address - Street 1:18540 E SAN TAN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-2203
Practice Address - Country:US
Practice Address - Phone:480-677-8202
Practice Address - Fax:480-677-8203
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ014046225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant