Provider Demographics
NPI:1699307520
Name:TISDALE, LATIA
Entity type:Individual
Prefix:
First Name:LATIA
Middle Name:
Last Name:TISDALE
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 1:6313 CALAVETTI DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-4180
Mailing Address - Country:US
Mailing Address - Phone:804-405-0009
Mailing Address - Fax:
Practice Address - Street 1:2520 PROFESSIONAL RD STE D
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-3267
Practice Address - Country:US
Practice Address - Phone:804-601-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1204019942174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist