Provider Demographics
NPI:1437628393
Name:CORNELSON, KENNA
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:
Last Name:CORNELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENNA
Other - Middle Name:
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12104 DORNICK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-6905
Mailing Address - Country:US
Mailing Address - Phone:405-618-1933
Mailing Address - Fax:
Practice Address - Street 1:6020 NW 120TH CT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-1729
Practice Address - Country:US
Practice Address - Phone:405-455-8668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist