MEDICARE: TIERNARY BROOKS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71012806A	IN

General Provider Information

NPI Number	:	1912632605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIERNARY BROOKS NP

Provider Business Mailing Address
First Line	:	7606 MELODY CIR W
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-4875
Country	:	US
Telephone Number	:	260-804-7617
Fax Number	:

Provider Business Practice Location Address
First Line	:	2626 FAIRFIELD AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-1215
Country	:	US
Telephone Number	:	260-235-5900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2022
Last Update Date	:	01/26/2023

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