Provider Demographics
NPI:1376564195
Name:CARLTON, TISH I'RENEE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TISH
Middle Name:I'RENEE
Last Name:CARLTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10634 SHADY PRESERVE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9310
Mailing Address - Country:US
Mailing Address - Phone:813-892-5159
Mailing Address - Fax:
Practice Address - Street 1:10634 SHADY PRESERVE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-9310
Practice Address - Country:US
Practice Address - Phone:813-892-5159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3092992363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305181100Medicaid
FL305181100Medicaid
FLE8947ZMedicare ID - Type Unspecified