Healthcare Provider Details

I. General information

NPI: 1538853601
Provider Name (Legal Business Name): KIMBERLY NICOLE CORNAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1723 CRESWELL LN EXT
OPELOUSAS LA
70570-7836
US

IV. Provider business mailing address

600 JEFFERSON ST STE 600
LAFAYETTE LA
70501-6987
US

V. Phone/Fax

Practice location:
  • Phone: 337-326-4569
  • Fax:
Mailing address:
  • Phone: 337-356-9886
  • Fax: 337-465-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number338342
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: