Healthcare Provider Details

I. General information

NPI: 1154432409
Provider Name (Legal Business Name): MS. COLLEEN KERNAHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 CAMPUS POINT DR SUITE 2D, #0996
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

1855 DIAMOND ST #5-322
SAN DIEGO CA
92109-3358
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7200
  • Fax:
Mailing address:
  • Phone: 858-273-3522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: