Provider Demographics
NPI:1992462329
Name:CORNELIUS, MARY KATHERINE (RN, CCM)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22633 BAY SHORE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-4414
Mailing Address - Country:US
Mailing Address - Phone:410-708-4617
Mailing Address - Fax:
Practice Address - Street 1:22633 BAY SHORE RD
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-4414
Practice Address - Country:US
Practice Address - Phone:410-708-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR173866163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management