Provider Demographics
NPI:1801653605
Name:CORNILSEN, MCKENZIE BETTE (CLC, SBD)
Entity type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:BETTE
Last Name:CORNILSEN
Suffix:
Gender:F
Credentials:CLC, SBD
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 623
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:IA
Mailing Address - Zip Code:52728-0623
Mailing Address - Country:US
Mailing Address - Phone:563-320-4698
Mailing Address - Fax:
Practice Address - Street 1:2010 E 38TH ST STE 201B
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1179
Practice Address - Country:US
Practice Address - Phone:184-656-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA374J00000X
IAALPP-330760174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula