Provider Demographics
NPI:1114946688
Name:CHURCH, KIERSTIN K (CRNA)
Entity Type:Individual
Prefix:MISS
First Name:KIERSTIN
Middle Name:K
Last Name:CHURCH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 W GRAND AVE
Mailing Address - Street 2:APT. 208
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1904
Mailing Address - Country:US
Mailing Address - Phone:207-593-6496
Mailing Address - Fax:
Practice Address - Street 1:1040 W GRAND AVE
Practice Address - Street 2:APT. 208
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1904
Practice Address - Country:US
Practice Address - Phone:207-593-6496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 487393163W00000X
CA487393367500000X
MER053337367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433004799Medicaid
ME000063302Medicare PIN