Provider Demographics
NPI:1386793834
Name:KIERNAN, GERALDINE E (CRNA)
Entity type:Individual
Prefix:
First Name:GERALDINE
Middle Name:E
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2679 GLEN ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1464
Mailing Address - Country:US
Mailing Address - Phone:719-331-7318
Mailing Address - Fax:
Practice Address - Street 1:715 N WEBER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1091
Practice Address - Country:US
Practice Address - Phone:719-473-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO123496367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34658572Medicaid
COC803827Medicare PIN