Provider Demographics
NPI:1528456506
Name:CORNELIUS, LINDSAY PLOEGER (PTA)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:PLOEGER
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18330 N 79TH AVE APT 2034
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8350
Mailing Address - Country:US
Mailing Address - Phone:801-560-7250
Mailing Address - Fax:
Practice Address - Street 1:18330 N 79TH AVE APT 2034
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8350
Practice Address - Country:US
Practice Address - Phone:801-560-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11318A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant