Healthcare Provider Details

I. General information

NPI: 1932802048
Provider Name (Legal Business Name): MAURA TIERNEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 5TH AVE
NEW YORK NY
10011-6902
US

IV. Provider business mailing address

333 S DESPLAINES ST STE 201
CHICAGO IL
60661-5514
US

V. Phone/Fax

Practice location:
  • Phone: 347-778-2542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF351322-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: