Provider Demographics
NPI:1689102915
Name:TIERNEY, STACY (LPN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 E STATE ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1204
Practice Address - Country:US
Practice Address - Phone:518-773-7931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298033251J00000X
NY733287163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTIERNES421OtherHEALTHCARE PROVIDER