Healthcare Provider Details

I. General information

NPI: 1205695145
Provider Name (Legal Business Name): KRISTEN ELIZABETH CORNELIUS MSN, AG-ACNP, CV-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN ELIZABETH WATERS

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 GORDON RD STE 102
JASPER GA
30143-1017
US

IV. Provider business mailing address

3970 DEP BILL CANTRELL MEMORIAL RD
CUMMING GA
30040-3011
US

V. Phone/Fax

Practice location:
  • Phone: 678-513-2273
  • Fax: 678-513-8869
Mailing address:
  • Phone: 678-513-2273
  • Fax: 678-513-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN278770
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN278770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: