Provider Demographics
NPI:1407565252
Name:TISDALE, SARAH ELIZABETH (RD, RN)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:TISDALE
Suffix:
Gender:F
Credentials:RD, RN
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:GOODERHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, RN
Mailing Address - Street 1:235 S PALISADE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5948
Mailing Address - Country:US
Mailing Address - Phone:805-739-3561
Mailing Address - Fax:805-739-3560
Practice Address - Street 1:235 PALISADE DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-739-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86059396133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORN.1681616OtherCOLORADO BOARD OF NURSING
86059396OtherCOMMISSION ON DIETETICS REGISTERED
CARN95293298OtherSTATE OF CALIFORNIA BOARD OF REGISTERED NURSING