Healthcare Provider Details

I. General information

NPI: 1184609331
Provider Name (Legal Business Name): PENNY S CORNELIUS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2618 FORESTVILLE DR
GREEN BAY WI
54304-1358
US

IV. Provider business mailing address

2618 FORESTVILLE DR
GREEN BAY WI
54304-1358
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-1631
  • Fax:
Mailing address:
  • Phone: 920-496-1631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number696-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: