MEDICARE: KELLY KIERNAN M.S.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		NY

General Provider Information

NPI Number	:	1568851558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY KIERNAN M.S.ED.

Provider Business Mailing Address
First Line	:	34 PENNSYLVANIA AVE
Second Line	:	APT. #1
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1622
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 PENNSYLVANIA AVE
Second Line	:	APT. #1
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1622
Country	:	US
Telephone Number	:	516-835-4721
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2015
Last Update Date	:	01/14/2015

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