Provider Demographics
NPI:1770606121
Name:TIERNEY, NICHOLE RENEE (OT)
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:RENEE
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 S 2ND AVE E
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-2723
Mailing Address - Country:US
Mailing Address - Phone:563-940-1794
Mailing Address - Fax:
Practice Address - Street 1:9929 RACE TRACK RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4458
Practice Address - Country:US
Practice Address - Phone:800-659-1522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63446014201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist