=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407657588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOY CORNELIUS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2025
-----------------------------------------------------
Last Update Date | 04/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1880 AFFIRMED CIR
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-7635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-779-9408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1880 AFFIRMED CIR
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-7635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOY CORNELIUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-779-9408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------