Basic Information
| Provider Information | |||||||||
| NPI: | 1508371014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISDALE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | SIMS | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Practice Location | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2017 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 9464937 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 9464937 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.