Provider Demographics
NPI:1003622705
Name:CORNELIUS, AMANDA (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CORNELIUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:5006 DONLAR AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-5329
Mailing Address - Country:US
Mailing Address - Phone:740-577-8813
Mailing Address - Fax:
Practice Address - Street 1:4320 BRIDGETOWN RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-4428
Practice Address - Country:US
Practice Address - Phone:740-577-8813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
OH007677225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant