Healthcare Provider Details

I. General information

NPI: 1790608289
Provider Name (Legal Business Name): KIERNAN MARK DEAN-HALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 OLD HOMESTEAD RD
GLEN ARBOR MI
49636-9720
US

IV. Provider business mailing address

1 OLD HOMESTEAD RD
GLEN ARBOR MI
49636-9720
US

V. Phone/Fax

Practice location:
  • Phone: 269-993-1472
  • Fax:
Mailing address:
  • Phone: 269-993-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number2015366
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: