Provider Demographics
NPI:1477029163
Name:TISDAL, STEPHANIE JEAN (MSN, A-GNP-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JEAN
Last Name:TISDAL
Suffix:
Gender:F
Credentials:MSN, A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8705 BRANDON STATION RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-4307
Mailing Address - Country:US
Mailing Address - Phone:479-462-5186
Mailing Address - Fax:
Practice Address - Street 1:1824 HILLANDALE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2650
Practice Address - Country:US
Practice Address - Phone:919-383-6107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011137363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner