Provider Demographics
NPI:1992553101
Name:TISDALE, BROOKLYNN T (LPN)
Entity type:Individual
Prefix:MISS
First Name:BROOKLYNN
Middle Name:T
Last Name:TISDALE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 DODGE ST APT D
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-1524
Mailing Address - Country:US
Mailing Address - Phone:585-362-2046
Mailing Address - Fax:
Practice Address - Street 1:60 DODGE ST APT D
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-1524
Practice Address - Country:US
Practice Address - Phone:585-362-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337414164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse