Provider Demographics
NPI:1447086129
Name:KIERNAN, BREEANNA MAKEN (RDN)
Entity type:Individual
Prefix:MRS
First Name:BREEANNA
Middle Name:MAKEN
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1614
Mailing Address - Country:US
Mailing Address - Phone:631-317-7989
Mailing Address - Fax:
Practice Address - Street 1:10 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1614
Practice Address - Country:US
Practice Address - Phone:631-317-7989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01213501133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered