Provider Demographics
NPI:1386496826
Name:CORNELIUS, PHYLLIS (LPN)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3330
Mailing Address - Country:US
Mailing Address - Phone:859-360-0254
Mailing Address - Fax:859-261-0801
Practice Address - Street 1:1717 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3330
Practice Address - Country:US
Practice Address - Phone:859-360-0254
Practice Address - Fax:859-261-0801
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2017284164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse