Provider Demographics
NPI:1295375855
Name:MCTIERNAN, SANDRA ALEXIS (RN)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ALEXIS
Last Name:MCTIERNAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:YOUNGBLOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1873 HART ST FL 2
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1122
Mailing Address - Country:US
Mailing Address - Phone:917-554-5765
Mailing Address - Fax:
Practice Address - Street 1:1873 HART ST FL 2
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1122
Practice Address - Country:US
Practice Address - Phone:917-554-5765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY682709-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice