Healthcare Provider Details

I. General information

NPI: 1417654799
Provider Name (Legal Business Name): NICOLE CORNELIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL PKWY
CARSON CITY NV
89703-4625
US

IV. Provider business mailing address

12 S POTOMAC ST
BALTIMORE MD
21224-2249
US

V. Phone/Fax

Practice location:
  • Phone: 775-445-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.0021076
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR243324
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: