Provider Demographics
NPI:1720251838
Name:CORNELIUS, VICTORIA L
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
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 1:2751 N PACKERLAND DR
Mailing Address - Street 2:#103
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4855
Mailing Address - Country:US
Mailing Address - Phone:920-496-9977
Mailing Address - Fax:
Practice Address - Street 1:2751 N PACKERLAND DR
Practice Address - Street 2:#103
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4855
Practice Address - Country:US
Practice Address - Phone:920-496-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0588019332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41688500Medicaid
WI0960800001Medicare NSC