Provider Demographics
NPI:1942830559
Name:TIERNEY, ROSALIE (RD)
Entity type:Individual
Prefix:
First Name:ROSALIE
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ROSALIE
Other - Middle Name:
Other - Last Name:SHANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:369 NE REVERE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4082
Mailing Address - Country:US
Mailing Address - Phone:541-323-3488
Mailing Address - Fax:541-323-3483
Practice Address - Street 1:369 NE REVERE AVE STE 105
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4082
Practice Address - Country:US
Practice Address - Phone:541-323-3488
Practice Address - Fax:541-323-3483
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
ORLD-D-10218001133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174H00000XOther Service ProvidersHealth Educator