Provider Demographics
NPI:1093430266
Name:CORNELISON, MADISON KATHLEEN (HIS)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:KATHLEEN
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 ROTTINGHAM CT STE C
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3778
Mailing Address - Country:US
Mailing Address - Phone:618-655-1385
Mailing Address - Fax:618-655-1393
Practice Address - Street 1:123 ROTTINGHAM CT STE C
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3778
Practice Address - Country:US
Practice Address - Phone:618-655-1385
Practice Address - Fax:618-655-1393
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3467237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist