Provider Demographics
NPI:1639570898
Name:TISDALE, MARY E (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:TISDALE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 MEADOW FARM S
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-1311
Mailing Address - Country:US
Mailing Address - Phone:585-694-3472
Mailing Address - Fax:
Practice Address - Street 1:215 MEADOW FARM S
Practice Address - Street 2:
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-1311
Practice Address - Country:US
Practice Address - Phone:585-694-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282611164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse