Provider Demographics
NPI:1114576154
Name:PIERCE, TINA MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:PIERCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3431
Mailing Address - Country:US
Mailing Address - Phone:219-878-5645
Mailing Address - Fax:
Practice Address - Street 1:809 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3431
Practice Address - Country:US
Practice Address - Phone:219-878-5645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009346A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily