Healthcare Provider Details

I. General information

NPI: 1801525779
Provider Name (Legal Business Name): SHAQUITA M CORNELIUS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 HIGHWAY 65 S
DUMAS AR
71639-3003
US

IV. Provider business mailing address

790 ROBERTS DR
MONTICELLO AR
71655-5723
US

V. Phone/Fax

Practice location:
  • Phone: 870-382-4001
  • Fax: 870-382-6094
Mailing address:
  • Phone: 870-367-2461
  • Fax: 870-460-6133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA2603005
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: