Provider Demographics
NPI:1346940665
Name:KERNS, KEILA MARINA
Entity Type:Individual
Prefix:
First Name:KEILA
Middle Name:MARINA
Last Name:KERNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2658 PERN PL
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5443
Mailing Address - Country:US
Mailing Address - Phone:707-227-6518
Mailing Address - Fax:
Practice Address - Street 1:2658 PERN PL
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5443
Practice Address - Country:US
Practice Address - Phone:707-227-6518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-305401174N00000X
CA86115720133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN