MEDICARE: LAURA JEAN CORNELIUS LPN

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	164W00000X	Licensed Practical Nurse	LPN.168973.MEDS-IV	OH

General Provider Information

NPI Number	:	1700351764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA JEAN CORNELIUS LPN

Provider Business Mailing Address
First Line	:	489 MCKINLEY ST
Second Line	:
City	:	MARION
State	:	OH
Zip	:	43302-4853
Country	:	US
Telephone Number	:	740-360-3603
Fax Number	:	740-387-4059

Provider Business Practice Location Address
First Line	:	333 E CENTER ST
Second Line	:
City	:	MARION
State	:	OH
Zip	:	43302-4142
Country	:	US
Telephone Number	:	740-375-5550
Fax Number	:

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

Provider Enumeration Date	:	10/05/2018
Last Update Date	:	10/05/2018

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