Provider Demographics
NPI:1366765232
Name:CORNELIUS, TAMMY (CRNP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 CLARK ST NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-1921
Mailing Address - Country:US
Mailing Address - Phone:256-736-5505
Mailing Address - Fax:256-736-5551
Practice Address - Street 1:1800 AL HIGHWAY 157
Practice Address - Street 2:SUITE 101
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35058-1271
Practice Address - Country:US
Practice Address - Phone:256-734-1012
Practice Address - Fax:256-739-3450
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-066972363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL117960Medicaid
E869OtherGRP MDCR