Provider Demographics
NPI:1760755243
Name:HERNDON, TISHA LYNN (LVN)
Entity Type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:LYNN
Last Name:HERNDON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 COMFORT DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-5075
Mailing Address - Country:US
Mailing Address - Phone:214-862-7442
Mailing Address - Fax:
Practice Address - Street 1:1012 COMFORT DR
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-5075
Practice Address - Country:US
Practice Address - Phone:214-862-7442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX166978164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse