Provider Demographics
NPI:1912568775
Name:TYISKA, SHANACIA
Entity Type:Individual
Prefix:
First Name:SHANACIA
Middle Name:
Last Name:TYISKA
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 1:308 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75603-7627
Mailing Address - Country:US
Mailing Address - Phone:903-736-9689
Mailing Address - Fax:
Practice Address - Street 1:308 MEADOWLARK LN
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75603-7627
Practice Address - Country:US
Practice Address - Phone:903-736-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX879044163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse