Basic Information
| Provider Information | |||||||||
| NPI: | 1366765232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNELIUS | ||||||||
| FirstName: | TAMMY | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 CLARK ST NE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350551921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567365505 | ||||||||
| FaxNumber: | 2567365551 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 AL HIGHWAY 157 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350581271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567341012 | ||||||||
| FaxNumber: | 2567393450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2010 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 1-066972 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 117960 | 05 | AL | MEDICAID | E869 | 01 | GRP MDCR | OTHER |