Provider Demographics
NPI:1952615387
Name:TISDALE, KACIE T (FNP)
Entity Type:Individual
Prefix:MS
First Name:KACIE
Middle Name:T
Last Name:TISDALE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:T
Other - Last Name:ROBERTUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2510 17TH ST W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-1736
Mailing Address - Country:US
Mailing Address - Phone:406-245-3238
Mailing Address - Fax:
Practice Address - Street 1:123 S 27TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-4227
Practice Address - Country:US
Practice Address - Phone:406-247-3350
Practice Address - Fax:406-247-3389
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT32201363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner