Provider Demographics
NPI:1023362175
Name:KERNOHAN, KIMBERLY (RDH)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KERNOHAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 SALT MARSH CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1172 SALT MARSH CIR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2542
Practice Address - Country:US
Practice Address - Phone:904-543-0537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-27
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH4047124Q00000X
CO201322124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist