Provider Demographics
NPI:1033855788
Name:TISDALE, SHERRONDA
Entity Type:Individual
Prefix:
First Name:SHERRONDA
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10903 HIGHLAND MEADOW VLG DR APT 404
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-5364
Mailing Address - Country:US
Mailing Address - Phone:832-271-9029
Mailing Address - Fax:800-391-2426
Practice Address - Street 1:630 W PRIEN LAKE RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0700
Practice Address - Country:US
Practice Address - Phone:281-506-0630
Practice Address - Fax:800-391-2426
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)