Healthcare Provider Details

I. General information

NPI: 1336696210
Provider Name (Legal Business Name): LILA CORNELIO RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 N UNIVERSITY DR
PLANTATION FL
33322-4107
US

IV. Provider business mailing address

4266 BROOKSIDE DR
PENSACOLA FL
32503-2868
US

V. Phone/Fax

Practice location:
  • Phone: 888-320-1776
  • Fax:
Mailing address:
  • Phone: 850-902-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1073156
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number10664
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: