Provider Demographics
NPI:1740850247
Name:CORNELISSEN, RYLIE ANNE
Entity type:Individual
Prefix:
First Name:RYLIE
Middle Name:ANNE
Last Name:CORNELISSEN
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 1:244 BARTON BLVD # 316
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2744
Mailing Address - Country:US
Mailing Address - Phone:715-563-8673
Mailing Address - Fax:
Practice Address - Street 1:2080 W EAU GALLIE BLVD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3185
Practice Address - Country:US
Practice Address - Phone:407-694-3603
Practice Address - Fax:321-296-7130
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ10127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty