Basic Information
| Provider Information | |||||||||
| NPI: | 1669098588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUD | ||||||||
| FirstName: | KIERNAN | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | BT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 W CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486579307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897505464 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2305 HAWTHORN DR STE A | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488581202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898606119 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2020 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.