Provider Demographics
NPI:1568228393
Name:TISDALE, ELLA (CRNA)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ELLA
Other - Middle Name:
Other - Last Name:MINTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4070 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-5033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4070 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5033
Practice Address - Country:US
Practice Address - Phone:843-652-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28445367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered