Healthcare Provider Details

I. General information

NPI: 1255490876
Provider Name (Legal Business Name): MEREDITH JANE KIESCHNICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 SEBASTOPOL RD ROSELAND CLINIC
SANTA ROSA CA
95407
US

IV. Provider business mailing address

2433 COFFEE LANE
SEBASTOPOL CA
95472
US

V. Phone/Fax

Practice location:
  • Phone: 707-578-2005
  • Fax: 707-578-8037
Mailing address:
  • Phone: 707-484-7944
  • Fax: 707-578-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG60980
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: