Provider Demographics
NPI:1487090726
Name:MARTZ, TISHA RANEIL (RN, BSN)
Entity type:Individual
Prefix:
First Name:TISHA
Middle Name:RANEIL
Last Name:MARTZ
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 WAGON TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5748
Mailing Address - Country:US
Mailing Address - Phone:307-688-5000
Mailing Address - Fax:
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-688-5000
Practice Address - Fax:307-688-5015
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY31871163WA0400X, 163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health