Provider Demographics
NPI:1275906828
Name:CORNELIUS, LORI A (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:A
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 N KINZIE AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1233
Mailing Address - Country:US
Mailing Address - Phone:815-933-2589
Mailing Address - Fax:815-634-5253
Practice Address - Street 1:990 N KINZIE AVE
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1233
Practice Address - Country:US
Practice Address - Phone:815-933-2589
Practice Address - Fax:815-634-5253
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704414731363LF0000X
IL209013527363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily