Healthcare Provider Details

I. General information

NPI: 1164187589
Provider Name (Legal Business Name): KELLY SUSAN CORNELIUS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 07/14/2023
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 5TH ST
HANFORD CA
93230-5029
US

IV. Provider business mailing address

1101 AVALON DR
LEMOORE CA
93245-9153
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 757-510-1549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86175798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: