Provider Demographics
NPI:1881296176
Name:TISDEL, SHERYL RENEE
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:RENEE
Last Name:TISDEL
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 1:15330 100TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LIDGERWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58053-9755
Mailing Address - Country:US
Mailing Address - Phone:701-640-2626
Mailing Address - Fax:
Practice Address - Street 1:15330 100TH ST SE
Practice Address - Street 2:
Practice Address - City:LIDGERWOOD
Practice Address - State:ND
Practice Address - Zip Code:58053-9755
Practice Address - Country:US
Practice Address - Phone:701-640-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDTIS-52-04493747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant