Provider Demographics
NPI:1659899664
Name:KERN, MARY (CNM, FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KERN
Suffix:
Gender:F
Credentials:CNM, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23141 MOULTON PKWY STE 108
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1241
Mailing Address - Country:US
Mailing Address - Phone:949-215-7575
Mailing Address - Fax:
Practice Address - Street 1:23141 MOULTON PKWY STE 108
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-215-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007186363LF0000X
367A00000X
CA74780163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse