Provider Demographics
NPI:1073706578
Name:TIERNEY, KELLY C-K (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C-K
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4281 LENNON RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1024
Mailing Address - Country:US
Mailing Address - Phone:810-720-9111
Mailing Address - Fax:810-720-9119
Practice Address - Street 1:4281 LENNON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1024
Practice Address - Country:US
Practice Address - Phone:810-720-9111
Practice Address - Fax:810-720-9119
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5725152W00000X
MI4901004430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist