Provider Demographics
NPI:1205469665
Name:CORNELIUS, TANYA LASHON
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:LASHON
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 1:504 ARLENE LN
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:GA
Mailing Address - Zip Code:31647-7238
Mailing Address - Country:US
Mailing Address - Phone:229-402-3833
Mailing Address - Fax:
Practice Address - Street 1:504 ARLENE LN
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:GA
Practice Address - Zip Code:31647-7238
Practice Address - Country:US
Practice Address - Phone:229-402-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor