Provider Demographics
NPI:1477033298
Name:TISDALE, FLEETINA (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:
First Name:FLEETINA
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CIMMARON CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-3147
Mailing Address - Country:US
Mailing Address - Phone:919-389-6155
Mailing Address - Fax:
Practice Address - Street 1:113 CIMMARON CT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-3147
Practice Address - Country:US
Practice Address - Phone:919-389-6155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8256235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist