Healthcare Provider Details

I. General information

NPI: 1851057731
Provider Name (Legal Business Name): NAKIA MARIE CORNELIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43862 CEDAR AVE
LANCASTER CA
93534-5043
US

IV. Provider business mailing address

4563 W AVENUE M4 UNIT N
QUARTZ HILL CA
93536-2948
US

V. Phone/Fax

Practice location:
  • Phone: 310-791-3064
  • Fax:
Mailing address:
  • Phone: 661-470-4906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: