Provider Demographics
NPI:1053350314
Name:KIERNAN, MAUREEN E (NP)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:E
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 656
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-5282
Mailing Address - Fax:585-273-1068
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0002
Practice Address - Country:US
Practice Address - Phone:585-275-5282
Practice Address - Fax:585-273-1068
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302262-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02533113Medicaid
NYDD5054Medicare PIN
NY02533113Medicaid