Provider Demographics
NPI:1134505134
Name:TIERNEY, CAROLINE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 DISTRICT AVE
Mailing Address - Street 2:APT 305
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901
Mailing Address - Country:US
Mailing Address - Phone:516-698-7746
Mailing Address - Fax:
Practice Address - Street 1:11915 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902
Practice Address - Country:US
Practice Address - Phone:301-942-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC001571363LF0000X
VA0024172771363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily