=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508142019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARON JANICE KERNEN PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2011
-----------------------------------------------------
Last Update Date | 10/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9001 GALAXIA WAY NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-263-8055
-----------------------------------------------------
Fax | 505-821-8775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9001 GALAXIA WAY NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-263-8055
-----------------------------------------------------
Fax | 505-821-8775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 1130
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------