Provider Demographics
NPI:1831775857
Name:CORNELISSEN, MACAELA JO (DNP, NNP-BC)
Entity type:Individual
Prefix:
First Name:MACAELA
Middle Name:JO
Last Name:CORNELISSEN
Suffix:
Gender:F
Credentials:DNP, NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 PARTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9651
Mailing Address - Country:US
Mailing Address - Phone:920-419-5498
Mailing Address - Fax:
Practice Address - Street 1:1376 PARTRIDGE RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9651
Practice Address - Country:US
Practice Address - Phone:920-419-5498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-21
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI234927163WN0002X
WI14025363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care