Provider Demographics
NPI:1003512179
Name:TISDALE, RACHEL ELIZABETH (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:ELIZABETH
Last Name:TISDALE
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:E
Other - Last Name:TISDALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8251 LAUREL LAKES WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-6793
Mailing Address - Country:US
Mailing Address - Phone:254-458-6647
Mailing Address - Fax:
Practice Address - Street 1:8251 LAUREL LAKES WAY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-6793
Practice Address - Country:US
Practice Address - Phone:254-458-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86077854133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered