Provider Demographics
NPI:1801996384
Name:TIERNEY, JOANNA L (MD)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:L
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198560
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 E KIMBALLS LN STE 260
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5009
Practice Address - Country:US
Practice Address - Phone:801-545-8480
Practice Address - Fax:801-253-1602
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240030207R00000X
WAMD00042465207R00000X
UT8738131-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G84521Medicare UPIN