Provider Demographics
NPI:1144928540
Name:TIERNEY, SANDRA JEAN
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 MEADOWSWEET DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-4077
Mailing Address - Country:US
Mailing Address - Phone:419-654-4138
Mailing Address - Fax:
Practice Address - Street 1:WALMART
Practice Address - Street 2:1275 E 2ND STREET
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005
Practice Address - Country:US
Practice Address - Phone:937-704-0809
Practice Address - Fax:937-704-0820
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017188-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician