Provider Demographics
NPI:1083208383
Name:KIERNAN, SAMANTHA GAIL (LMT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAIL
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42210-0383
Mailing Address - Country:US
Mailing Address - Phone:270-784-2379
Mailing Address - Fax:
Practice Address - Street 1:1671 BEAVER DAM CHAPEL RD
Practice Address - Street 2:
Practice Address - City:SMITHS GROVE
Practice Address - State:KY
Practice Address - Zip Code:42171-8827
Practice Address - Country:US
Practice Address - Phone:270-784-4438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist