Provider Demographics
NPI:1215216379
Name:KIERNAN, KRISTEN M (PT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:M
Other - Last Name:BIXLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2562 W SCHAUMBURG RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-3897
Practice Address - Country:US
Practice Address - Phone:847-519-3485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-018654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216859196Medicare PIN