Healthcare Provider Details

I. General information

NPI: 1942830559
Provider Name (Legal Business Name): ROSALIE TIERNEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSALIE SHANKS RD

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 NE REVERE AVE STE 105
BEND OR
97701-4082
US

IV. Provider business mailing address

369 NE REVERE AVE STE 105
BEND OR
97701-4082
US

V. Phone/Fax

Practice location:
  • Phone: 541-323-3488
  • Fax: 541-323-3483
Mailing address:
  • Phone: 541-323-3488
  • Fax: 541-323-3483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10218001
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: