Provider Demographics
NPI:1134298813
Name:TIERNEY, DANYELLE M (DO)
Entity Type:Individual
Prefix:
First Name:DANYELLE
Middle Name:M
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 700
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-523-8597
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEDO1903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400309774Medicare PIN
I45796Medicare UPIN