Provider Demographics
NPI:1497150221
Name:MINASSIAN, TIERENY (APN)
Entity Type:Individual
Prefix:MRS
First Name:TIERENY
Middle Name:
Last Name:MINASSIAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2024
Mailing Address - Country:US
Mailing Address - Phone:309-266-8900
Mailing Address - Fax:309-263-6788
Practice Address - Street 1:110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2024
Practice Address - Country:US
Practice Address - Phone:309-266-8900
Practice Address - Fax:309-263-6788
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily