Healthcare Provider Details

I. General information

NPI: 1750963484
Provider Name (Legal Business Name): MICHELLE LAUREN TIERNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

6000 BUCKHORN LAKE RD
HIGHLAND MI
48357-2314
US

V. Phone/Fax

Practice location:
  • Phone: 928-214-2920
  • Fax:
Mailing address:
  • Phone: 248-660-3563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number11712
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: