Provider Demographics
NPI:1073966008
Name:TIERNAN, KRISTINA ELIZABETH (RDN)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ELIZABETH
Last Name:TIERNAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:ELIZABETH
Other - Last Name:FALLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDN
Mailing Address - Street 1:3500 MOUNTAIN GLADE DR
Mailing Address - Street 2:APT 11
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-7745
Mailing Address - Country:US
Mailing Address - Phone:603-440-8623
Mailing Address - Fax:
Practice Address - Street 1:3500 MOUNTAIN GLADE DR
Practice Address - Street 2:APT 11
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-7745
Practice Address - Country:US
Practice Address - Phone:603-440-8623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1058645133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered