Provider Demographics
NPI:1215692488
Name:CORNELLISON, JENNIFER (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CORNELLISON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-1028
Mailing Address - Country:US
Mailing Address - Phone:865-123-4567
Mailing Address - Fax:
Practice Address - Street 1:961 OAK RIDGE TPKE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-8832
Practice Address - Country:US
Practice Address - Phone:865-296-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000129572163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse