Provider Demographics
NPI:1255947750
Name:KENYON, KIERA (ATC)
Entity type:Individual
Prefix:
First Name:KIERA
Middle Name:
Last Name:KENYON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SHORT 6TH ST # B
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12188-2223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 SHORT 6TH ST APT B
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:NY
Practice Address - Zip Code:12188-2223
Practice Address - Country:US
Practice Address - Phone:518-641-9278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-20
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0031612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty