Provider Demographics
NPI:1538119227
Name:CORNELISON, VANCE LEE (D C)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:LEE
Last Name:CORNELISON
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 242161
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-0021
Mailing Address - Country:US
Mailing Address - Phone:501-221-8640
Mailing Address - Fax:501-221-4379
Practice Address - Street 1:11523 KANIS RD
Practice Address - Street 2:SUITE D
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3724
Practice Address - Country:US
Practice Address - Phone:501-221-8640
Practice Address - Fax:501-221-4379
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1606111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152951718Medicaid
AR152951718Medicaid