Provider Demographics
NPI:1508644402
Name:KIERNAN, KRISTIN
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KIERNAN
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 1:655 DEER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-9240
Mailing Address - Country:US
Mailing Address - Phone:870-403-8287
Mailing Address - Fax:
Practice Address - Street 1:3348 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-5013
Practice Address - Country:US
Practice Address - Phone:501-443-3818
Practice Address - Fax:501-521-1001
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARTEMP226202363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARTEMP226202OtherASBN LICENSE NUMBER