Provider Demographics
NPI:1093067274
Name:CORNELIUS, ANISSA NISHIRA (IBCLC)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:NISHIRA
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 GOLD COAST DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3606
Mailing Address - Country:US
Mailing Address - Phone:858-361-6392
Mailing Address - Fax:
Practice Address - Street 1:8550 GOLD COAST DR STE 140
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-3606
Practice Address - Country:US
Practice Address - Phone:951-347-5418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-314425174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN