Provider Demographics
NPI:1174611719
Name:KIERNAN, L SHULTIS (OTR)
Entity type:Individual
Prefix:MRS
First Name:L
Middle Name:SHULTIS
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31833
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33420-1833
Mailing Address - Country:US
Mailing Address - Phone:561-366-0065
Mailing Address - Fax:561-366-0078
Practice Address - Street 1:3401 PGA BLVD
Practice Address - Street 2:500B
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:561-366-0065
Practice Address - Fax:561-366-0078
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT674174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1322OtherBLUE CROSS/ BLUE SHIELD
FL890472300Medicaid
FLZ1322OtherBLUE CROSS/ BLUE SHIELD
FLZ1322ZMedicare PIN