1114407632 NPI number — MRS. TIERNEY SIEVERS WHITEHEAD BA

Table of content: MRS. TIERNEY SIEVERS WHITEHEAD BA (NPI 1114407632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114407632 NPI number — MRS. TIERNEY SIEVERS WHITEHEAD BA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITEHEAD
Provider First Name:
TIERNEY
Provider Middle Name:
SIEVERS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIEVERS
Provider Other First Name:
TIERNEY
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114407632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2428 WINCHESTER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32092-1086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-993-2554
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2392 EDGEWOOD AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32254-1725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-781-7797
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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