Provider Demographics
NPI:1669113874
Name:KERNAN, KRISTINE ELIZABETH
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:KERNAN
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 1:15980 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3455
Mailing Address - Country:US
Mailing Address - Phone:313-580-5677
Mailing Address - Fax:
Practice Address - Street 1:15980 HARRISON ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3455
Practice Address - Country:US
Practice Address - Phone:313-580-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704312102364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology