Provider Demographics
NPI:1508540212
Name:CORNELISON, IVY ANN (MS)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:ANN
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 CHARLOTTE AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-4059
Mailing Address - Country:US
Mailing Address - Phone:708-308-8820
Mailing Address - Fax:
Practice Address - Street 1:2229 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0001
Practice Address - Country:US
Practice Address - Phone:615-936-8422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program