Provider Demographics
NPI:1053578765
Name:CORNELIUS, STACEY LYNN (MPT)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 S SCHUMAKER DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-9256
Mailing Address - Country:US
Mailing Address - Phone:410-546-3492
Mailing Address - Fax:410-546-3492
Practice Address - Street 1:1109 S SCHUMAKER DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-9256
Practice Address - Country:US
Practice Address - Phone:410-546-3492
Practice Address - Fax:410-546-3492
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist