Provider Demographics
NPI:1336629328
Name:CORNIER, KENZIE KAY (BS, PTA)
Entity Type:Individual
Prefix:MRS
First Name:KENZIE
Middle Name:KAY
Last Name:CORNIER
Suffix:
Gender:F
Credentials:BS, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 GEORGE DIETER DR APT 1022
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7673
Mailing Address - Country:US
Mailing Address - Phone:574-601-7659
Mailing Address - Fax:
Practice Address - Street 1:1514 N ZARAGOZA RD STE B4
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8041
Practice Address - Country:US
Practice Address - Phone:915-257-5782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21419225200000X
TX2141976225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2141926Medicaid