Provider Demographics
NPI:1710491386
Name:CORNELIUS, DANIKA CLAIRE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIKA
Middle Name:CLAIRE
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6413 JENNY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-8919
Mailing Address - Country:US
Mailing Address - Phone:863-241-1520
Mailing Address - Fax:863-368-8008
Practice Address - Street 1:17393 MISSOURI RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-2832
Practice Address - Country:US
Practice Address - Phone:239-293-4749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-19
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110803363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9110803OtherFL BOARD OF MEDICINE
1143937OtherNCCPA