Provider Demographics
NPI:1568406791
Name:CORNELISON, DIANE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:121 CAHILL RD STE 204
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-1911
Practice Address - Country:US
Practice Address - Phone:417-335-7222
Practice Address - Fax:417-335-7224
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1008822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO248623407Medicaid
323671OtherHEALTHLINK
114695OtherBCBS
P00306557OtherRAILROAD MEDICARE
MO248623407Medicaid
MO248623407Medicaid
P00306557OtherRAILROAD MEDICARE