Provider Demographics
NPI:1578270955
Name:WALLACE, TIERNEY
Entity Type:Individual
Prefix:MISS
First Name:TIERNEY
Middle Name:
Last Name:WALLACE
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 1:5455 SATINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70812-3055
Mailing Address - Country:US
Mailing Address - Phone:225-907-8603
Mailing Address - Fax:
Practice Address - Street 1:5455 SATINWOOD DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70812-3055
Practice Address - Country:US
Practice Address - Phone:225-907-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)