Provider Demographics
NPI:1023147329
Name:KIERNAN, ERICA J (PT/OT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:J
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:PT/OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 SHAMROCK RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6562
Mailing Address - Country:US
Mailing Address - Phone:904-794-5880
Mailing Address - Fax:
Practice Address - Street 1:105 MARINER HEALTH WAY
Practice Address - Street 2:STE 213
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3251
Practice Address - Country:US
Practice Address - Phone:904-217-4259
Practice Address - Fax:904-217-4251
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 21925225100000X
FLOT12930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBW989ZMedicare PIN