Provider Demographics
NPI:1124564794
Name:TISDALE, SHAUNDA
Entity Type:Individual
Prefix:
First Name:SHAUNDA
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 1:3501 S SONCY RD STE 137
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6406
Mailing Address - Country:US
Mailing Address - Phone:806-331-6084
Mailing Address - Fax:806-331-6085
Practice Address - Street 1:3501 S SONCY RD STE 137
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119
Practice Address - Country:US
Practice Address - Phone:806-331-6084
Practice Address - Fax:806-331-6085
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1147430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist