Provider Demographics
NPI:1679792493
Name:TIERNEY, LETITIA ELAINE (MD)
Entity type:Individual
Prefix:DR
First Name:LETITIA
Middle Name:ELAINE
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2699
Mailing Address - Country:US
Mailing Address - Phone:304-344-2345
Mailing Address - Fax:304-400-4645
Practice Address - Street 1:10 COURTNEY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2699
Practice Address - Country:US
Practice Address - Phone:304-344-2345
Practice Address - Fax:304-400-4645
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23148208000000X, 208M00000X, 207R00000X, 207R00000X
WV2314207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1679792493Medicaid
P00947179Medicare UPIN