Provider Demographics
NPI:1447978994
Name:CORNELIA, NATASSIA MICHELLE
Entity type:Individual
Prefix:
First Name:NATASSIA
Middle Name:MICHELLE
Last Name:CORNELIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S STATE ST UNIT 140
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-8521
Mailing Address - Country:US
Mailing Address - Phone:541-515-9661
Mailing Address - Fax:
Practice Address - Street 1:1430 GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1766
Practice Address - Country:US
Practice Address - Phone:541-673-1750
Practice Address - Fax:541-672-0584
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT0013204183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician