Provider Demographics
NPI:1245799915
Name:KIERNAN, CASEY (RDN, CPT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:RDN, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 HIGH RIDGE WAY APT 306
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-8797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4725 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-202-0277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86082340133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered