Provider Demographics
NPI:1306594429
Name:LAIDLEY, TISHEKA
Entity type:Individual
Prefix:
First Name:TISHEKA
Middle Name:
Last Name:LAIDLEY
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 1:5036 ESTONIAN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-2157
Mailing Address - Country:US
Mailing Address - Phone:163-156-8914
Mailing Address - Fax:
Practice Address - Street 1:8606 NW 36TH ST # 107
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6665
Practice Address - Country:US
Practice Address - Phone:163-156-8914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN105085164W00000X
146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No164W00000XNursing Service ProvidersLicensed Practical Nurse