Healthcare Provider Details

I. General information

NPI: 1932624020
Provider Name (Legal Business Name): KRISTINE TIERNEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 CONNECTICUT DR
CROWN POINT IN
46307-7486
US

IV. Provider business mailing address

1004 PARKWAY AVE
ELKHART IN
46516-9348
US

V. Phone/Fax

Practice location:
  • Phone: 547-596-9558
  • Fax:
Mailing address:
  • Phone: 574-596-9558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.368412
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28227179A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28227179A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: