Healthcare Provider Details

I. General information

NPI: 1609038132
Provider Name (Legal Business Name): KATHLEEN KORNACKI RD, CDN, CSP, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 04/13/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3980A SHERIDAN DR
AMHERST NY
14226-1741
US

IV. Provider business mailing address

3980A SHERIDAN DR
AMHERST NY
14226-1741
US

V. Phone/Fax

Practice location:
  • Phone: 716-631-8400
  • Fax: 716-631-8408
Mailing address:
  • Phone: 716-631-8400
  • Fax: 716-631-8408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006449
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: