Provider Demographics
NPI:1255571139
Name:CORNELIUS, PAMELA (RD/LDN)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 X RAY DR STE B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7491
Mailing Address - Country:US
Mailing Address - Phone:704-884-0064
Mailing Address - Fax:704-884-0074
Practice Address - Street 1:2711 X RAY DR STE B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7491
Practice Address - Country:US
Practice Address - Phone:704-884-0064
Practice Address - Fax:704-884-0074
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002111133V00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC152YROtherBCBS NC