Provider Demographics
NPI:1265585202
Name:KERNAN, HENRIETTA (DO)
Entity type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:
Last Name:KERNAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-654-7300
Mailing Address - Fax:617-654-7164
Practice Address - Street 1:147 MILK ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-4806
Practice Address - Country:US
Practice Address - Phone:617-654-7300
Practice Address - Fax:617-654-7164
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2378672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2163179Medicaid
MA2163179Medicaid