Provider Demographics
NPI:1760713101
Name:TIERNEY, SEAN PATRICK (LMT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:TIERNEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 FAN PALM PL
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-7743
Mailing Address - Country:US
Mailing Address - Phone:850-319-1006
Mailing Address - Fax:
Practice Address - Street 1:2629 W 23RD ST
Practice Address - Street 2:E
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2311
Practice Address - Country:US
Practice Address - Phone:850-215-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL57885225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist