Provider Demographics
NPI:1477217800
Name:FIYISA, TIGIST TADESSE
Entity Type:Individual
Prefix:
First Name:TIGIST
Middle Name:TADESSE
Last Name:FIYISA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 UPPER 179TH ST W # NA
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4930
Mailing Address - Country:US
Mailing Address - Phone:651-235-8272
Mailing Address - Fax:
Practice Address - Street 1:5650 UPPER 179TH ST W # NA
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-4930
Practice Address - Country:US
Practice Address - Phone:651-235-8272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2475789163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2475789OtherREGISTERED NURSE LICENSE NUMBER