Provider Demographics
NPI:1457918765
Name:CORNELIUS, MARAH TAMIKA (NP-C)
Entity type:Individual
Prefix:MISS
First Name:MARAH
Middle Name:TAMIKA
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MRS
Other - First Name:MARAH
Other - Middle Name:TAMIKA
Other - Last Name:CORNELIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4000
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8LT456OtherBCBS
TX403562802OtherCSHCN MEDICAID
TX403562801Medicaid