Provider Demographics
NPI:1538740469
Name:TIERNAN, JACLYN (RN)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:TIERNAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55A S HOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1138
Mailing Address - Country:US
Mailing Address - Phone:631-993-1336
Mailing Address - Fax:
Practice Address - Street 1:55A S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1138
Practice Address - Country:US
Practice Address - Phone:631-993-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY702849163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics