Provider Demographics
NPI:1114004579
Name:KERNIG, MIKELLE LOUELLA (BM, DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MIKELLE
Middle Name:LOUELLA
Last Name:KERNIG
Suffix:
Gender:F
Credentials:BM, DDS, MS
Other - Prefix:DR
Other - First Name:MIKELLE
Other - Middle Name:LOUELLA
Other - Last Name:KUEHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:PO BOX 3405
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3405
Mailing Address - Country:US
Mailing Address - Phone:509-892-2700
Mailing Address - Fax:509-892-2740
Practice Address - Street 1:13103 E MANSFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1642
Practice Address - Country:US
Practice Address - Phone:509-892-2700
Practice Address - Fax:509-892-2740
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122371223P0106X
WAMD607973891223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2130862Medicaid