Provider Demographics
NPI:1932624020
Name:TIERNEY, KRISTINE (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 PARKWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9348
Mailing Address - Country:US
Mailing Address - Phone:574-596-9558
Mailing Address - Fax:
Practice Address - Street 1:9301 CONNECTICUT DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7486
Practice Address - Country:US
Practice Address - Phone:547-596-9558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.368412163W00000X
IN28227179A163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse