Provider Demographics
NPI:1528102001
Name:KERNEBECK, OLIVIA DAWN
Entity type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:DAWN
Last Name:KERNEBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3119 VALLEY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-4364
Mailing Address - Country:US
Mailing Address - Phone:636-461-2761
Mailing Address - Fax:
Practice Address - Street 1:3119 VALLEY OAKS DR
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-4364
Practice Address - Country:US
Practice Address - Phone:636-461-2761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005428225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics