Provider Demographics
NPI:1790384329
Name:TISDELL, SHANNON (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TISDELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7587 WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6982
Mailing Address - Country:US
Mailing Address - Phone:662-313-7520
Mailing Address - Fax:
Practice Address - Street 1:6674 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7056
Practice Address - Country:US
Practice Address - Phone:662-985-7806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904149363LF0000X
TN27722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily