MEDICARE: ELLISA BRIANNE CORNELIUS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	APRN11041237	FL

General Provider Information

NPI Number	:	1245118686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLISA BRIANNE CORNELIUS APRN

Provider Business Mailing Address
First Line	:	3607 MEDULLA RD
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33566-4515
Country	:	US
Telephone Number	:	813-629-9060
Fax Number	:

Provider Business Practice Location Address
First Line	:	331 S FLORIDA AVE STE 201
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4626
Country	:	US
Telephone Number	:	863-329-2750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2025
Last Update Date	:	10/07/2025

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