Provider Demographics
NPI:1922654631
Name:LEACH, TIERNEY C
Entity Type:Individual
Prefix:
First Name:TIERNEY
Middle Name:C
Last Name:LEACH
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 1:6880 W GRANTOSA DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-2907
Mailing Address - Country:US
Mailing Address - Phone:414-202-8382
Mailing Address - Fax:
Practice Address - Street 1:14860 JOLENTA LN
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-1025
Practice Address - Country:US
Practice Address - Phone:414-378-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3214002164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse