Provider Demographics
NPI:1316618317
Name:MIERZEJEWSKA, KORNELIA
Entity type:Individual
Prefix:
First Name:KORNELIA
Middle Name:
Last Name:MIERZEJEWSKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12789-5813
Mailing Address - Country:US
Mailing Address - Phone:347-515-5551
Mailing Address - Fax:
Practice Address - Street 1:53 MEADOWLARK LN
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12789-5813
Practice Address - Country:US
Practice Address - Phone:347-515-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010690225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant