Provider Demographics
NPI:1922791920
Name:CORNELIUS, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:
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 79
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-0079
Mailing Address - Country:US
Mailing Address - Phone:662-869-3700
Mailing Address - Fax:
Practice Address - Street 1:379 MOBILE STREET
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866
Practice Address - Country:US
Practice Address - Phone:662-869-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0582133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered