Provider Demographics
NPI:1770292591
Name:CORNELIUS, KADIE
Entity type:Individual
Prefix:
First Name:KADIE
Middle Name:
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 1:291 INDEPENDENCE BLVD.
Mailing Address - Street 2:PEMBROKE 4 SUITE 132
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-497-3900
Mailing Address - Fax:
Practice Address - Street 1:905 HALSTEAD BLVD STE 2
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6815
Practice Address - Country:US
Practice Address - Phone:252-392-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2430237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist