Provider Demographics
NPI:1083919401
Name:KORNIECK, KIMBERLY ANN (MT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:KORNIECK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 STONE ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3525
Mailing Address - Country:US
Mailing Address - Phone:810-941-4256
Mailing Address - Fax:
Practice Address - Street 1:1117 STONE ST
Practice Address - Street 2:SUITE 4
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3525
Practice Address - Country:US
Practice Address - Phone:810-941-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-15
Last Update Date:2011-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist