Provider Demographics
NPI:1285875211
Name:KERNEEN, NICOLE (RD,CD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KERNEEN
Suffix:
Gender:F
Credentials:RD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 ELM LAWN ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3031
Mailing Address - Country:US
Mailing Address - Phone:414-940-6662
Mailing Address - Fax:
Practice Address - Street 1:1149 ELM LAWN ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-940-6662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-21
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1461-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered