Provider Demographics
NPI:1457719601
Name:CORNELIUS, EVONYA (CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:EVONYA
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3034 DONNA DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208
Mailing Address - Country:US
Mailing Address - Phone:904-477-8801
Mailing Address - Fax:
Practice Address - Street 1:9355 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5503
Practice Address - Country:US
Practice Address - Phone:904-739-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist