Provider Demographics
NPI:1043817620
Name:CORNELISON, KELLY LYNN (PA-C, RT (R))
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LYNN
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:PA-C, RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DUKE MEDICINE CIR # 2-2
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 DUKE MEDICINE CIR # 2-2
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-2000
Practice Address - Country:US
Practice Address - Phone:919-668-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14464363A00000X
MA390200000X
MAPA8440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program