Healthcare Provider Details

I. General information

NPI: 1508195215
Provider Name (Legal Business Name): TIERNEY MARIE O'CONNELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E UNIVERSITY PKWY 33RD ST. PROF. BLDG., SUITE 226
BALTIMORE MD
21218-2829
US

IV. Provider business mailing address

936 STORMONT CIR
HALETHORPE MD
21227-3815
US

V. Phone/Fax

Practice location:
  • Phone: 410-299-2692
  • Fax:
Mailing address:
  • Phone: 410-299-2692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR170671
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: