Provider Demographics
NPI:1992240485
Name:CORNELIUS, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
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 1:607 E BERRIEN ST
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1616
Mailing Address - Country:US
Mailing Address - Phone:269-539-1956
Mailing Address - Fax:
Practice Address - Street 1:607 E BERRIEN ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1616
Practice Address - Country:US
Practice Address - Phone:269-539-1956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other