Provider Demographics
NPI:1174309298
Name:TISDALE, SANDRA (CNA/BSC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:CNA/BSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7061 VIBURNUM DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-2471
Mailing Address - Country:US
Mailing Address - Phone:907-764-4410
Mailing Address - Fax:
Practice Address - Street 1:7061 VIBURNUM DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-2471
Practice Address - Country:US
Practice Address - Phone:907-764-4410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS168128376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty