Healthcare Provider Details

I. General information

NPI: 1093067274
Provider Name (Legal Business Name): ANISSA NISHIRA CORNELIUS LM, CPM, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 FANUEL ST
SAN DIEGO CA
92109-2904
US

IV. Provider business mailing address

8550 GOLD COAST DR
SAN DIEGO CA
92126-3606
US

V. Phone/Fax

Practice location:
  • Phone: 858-900-2004
  • Fax:
Mailing address:
  • Phone: 858-361-6392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number765
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-314425
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: