Provider Demographics
NPI:1730079856
Name:CORNELIUS, ANTOINETTE (CLC)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 E WILEY LN
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-9716
Mailing Address - Country:US
Mailing Address - Phone:520-507-0286
Mailing Address - Fax:
Practice Address - Street 1:3081 E WILEY LN
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-9716
Practice Address - Country:US
Practice Address - Phone:520-507-0286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ361012174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN