Provider Demographics
NPI:1245463199
Name:TISDALE, AMY J (LPN)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:J
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 1:509 MAXON ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1952
Mailing Address - Country:US
Mailing Address - Phone:920-324-3467
Mailing Address - Fax:
Practice Address - Street 1:509 MAXON ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1952
Practice Address - Country:US
Practice Address - Phone:920-324-3467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33107031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse