=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790608289
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIERNAN MARK DEAN-HALL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2026
-----------------------------------------------------
Last Update Date | 08/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 OLD HOMESTEAD RD
-----------------------------------------------------
City | GLEN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49636-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-993-1472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 OLD HOMESTEAD RD
-----------------------------------------------------
City | GLEN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49636-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-993-1472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146N00000X
-----------------------------------------------------
Taxonomy Name | Basic Emergency Medical Technician
-----------------------------------------------------
License Number | 2015366
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------