Provider Demographics
NPI:1467125831
Name:LANDERS, TYISHA NICOLE (CNA)
Entity Type:Individual
Prefix:
First Name:TYISHA
Middle Name:NICOLE
Last Name:LANDERS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E VAN LAKE DR APT E
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-3250
Mailing Address - Country:US
Mailing Address - Phone:937-581-6876
Mailing Address - Fax:
Practice Address - Street 1:101 E VAN LAKE DR APT E
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-3250
Practice Address - Country:US
Practice Address - Phone:937-581-6876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide