Healthcare Provider Details

I. General information

NPI: 1548149065
Provider Name (Legal Business Name): NATALIE KENDALL CORNELISON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

12885 SW 1ST LN APT 412
NEWBERRY FL
32669-3587
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-1611
  • Fax:
Mailing address:
  • Phone: 408-335-8784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPR916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: