Provider Demographics
NPI:1033517768
Name:TISDALE, LACY REBAKA (NP-C)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:REBAKA
Last Name:TISDALE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:42 CABIN CREEK DIRVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305
Mailing Address - Country:US
Mailing Address - Phone:870-413-2203
Mailing Address - Fax:
Practice Address - Street 1:2054 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7741
Practice Address - Country:US
Practice Address - Phone:731-499-8708
Practice Address - Fax:731-499-8709
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004241363LF0000X
TN25492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily