Provider Demographics
NPI:1467514802
Name:CORNELIUS, KATHY CAMILLE (MD)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:CAMILLE
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18488
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-8488
Mailing Address - Country:US
Mailing Address - Phone:256-534-8659
Mailing Address - Fax:256-533-0276
Practice Address - Street 1:751 PLEASANT ROW NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-2537
Practice Address - Country:US
Practice Address - Phone:256-533-6311
Practice Address - Fax:256-536-3403
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD435367207Q00000X
AL37020207Q00000X
PAMT188604207Q00000X
MDD80148207Q00000X
ALMD37020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL314179Medicaid