Provider Demographics
NPI:1447825070
Name:SCOTT, TIERRA KAYE (CRNA)
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:KAYE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TIERRA
Other - Middle Name:KAYE
Other - Last Name:PENICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1937 ALVORD ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1849
Mailing Address - Country:US
Mailing Address - Phone:812-798-9111
Mailing Address - Fax:
Practice Address - Street 1:3200 SYCAMORE CT STE 1B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-1545
Practice Address - Country:US
Practice Address - Phone:812-378-9027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28223444A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN134706Medicaid