Provider Demographics
NPI:1043007909
Name:GATSON, TISHA
Entity type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:GATSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 AUTUMN OAK CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7647
Mailing Address - Country:US
Mailing Address - Phone:217-766-2650
Mailing Address - Fax:
Practice Address - Street 1:2406 AUTUMN OAK CT
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7647
Practice Address - Country:US
Practice Address - Phone:217-766-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174N00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RN